AF after PCI: a DOAC plus P2Y12 inhibitor halved major bleeding without a clear ischaemic cost at one year

Design

Individual patient data network meta-analysis of randomised trials

Population

6 trials, 10,634 patients with AF undergoing PCI

Primary outcome

CV death, MI or stroke; TIMI major bleeding at 1 year

Effect

Efficacy HR 1.16 (0.97 to 1.41); major bleeding HR 0.48 (0.38 to 0.65) vs VKA plus DAPT

A patient-level network meta-analysis combined six randomised trials of antithrombotic therapy in patients with atrial fibrillation (AF) undergoing PCI: 10,634 patients on DOAC plus P2Y12 inhibitor, VKA plus single antiplatelet, VKA plus dual antiplatelet (DAPT), or DOAC plus DAPT.

At one year, cardiovascular death, MI or stroke did not differ across strategies, with no interaction by age, sex, bleeding or thrombotic risk. DOAC plus P2Y12 inhibitor reduced TIMI major bleeding against VKA plus DAPT (HR 0.48) and VKA plus single antiplatelet (0.62), and intracranial haemorrhage against VKA plus DAPT (0.21). But a 14-day landmark analysis showed more MI and stent thrombosis early after PCI on the single-antiplatelet strategies.

This confirms the default of a DOAC with clopidogrel, and it quantifies the trade-off at the front end. The early ischaemic signal supports keeping aspirin for a short peri-PCI period in patients at high thrombotic risk, rather than dropping it on day one for everyone.

• Default to a DOAC plus clopidogrel after PCI in AF
• Consider aspirin for up to a week to a month when stent thrombosis risk is high
• Avoid VKA-based triple therapy unless a DOAC is contraindicated
• Reassess bleeding risk before discharge and record the planned stop date for each agent

Why it matters

It puts a number on the early ischaemic price of dropping aspirin, which is where individual judgement actually lies.

Don't overread it

The 14-day landmark finding is exploratory and does not define how long aspirin should continue.

The statistics, in plain English

The efficacy hazard ratio of 1.16 for DOAC plus P2Y12 (0.97 to 1.41) crosses 1, so no difference was shown, but the interval also allows up to 41% more ischaemic events, which is why the authors say a modest increase cannot be excluded. The bleeding HR of 0.48 (0.38 to 0.65) is a clear halving. Using individual patient data rather than published summaries makes subgroup and timing analyses more reliable.

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