Comparative Safety and Efficacy of Second-Generation P2Y12 Inhibitors Versus Clopidogrel in Combination With Oral Anticoagulation in Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis

Background: Following percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF) and CHA2DS2-VASc score ≥2, combination antiplatelet and oral anticoagulant (OAC) therapy is indicated. Dual therapy appears to be favorable to triple therapy with regard to bleeding; however, the optimal P2Y12 inhibitor remains in question. This study aimed to compare the safety and efficacy of second-generation P2Y12 inhibitors versus clopidogrel in combination with OAC in patients with AF undergoing PCI. Methods: The authors performed a systematic review including studies that compared dual and triple antithrombotic regimens for bleeding and major adverse cardiac events (MACE) in patients with AF undergoing PCI. The authors analyzed rates of bleeding and MACE by P2Y12 inhibitor choice. Risk ratio (RR) 95% confidence intervals (CI) were measured using the Mantel-Haenszel method. Where study heterogeneity was low (I2 \u3c 25%), the fixed-effects model was used, otherwise the random-effects model was used. Results: Seven studies, including 3 randomized controlled trials, with a total of 22,014 patients were analyzed. Among patients treated with both OAC and P2Y12 inhibitor, 90% were treated with clopidogrel, 8% with ticagrelor, and 2% with prasugrel. When compared with clopidogrel, use of ticagrelor (RR: 1.36; 95% CI: 1.18 to 1.57) and prasugrel (RR: 2.11; 95% CI: 1.34 to 3.30) led to increased rates of bleeding. There was no significant difference in rates of MACE between ticagrelor (RR: 1.03; 95% CI: 0.65 to 1.62) and prasugrel (RR: 1.49; 95% CI: 0.69 to 3.24) when compared with clopidogrel (Figure). [Figure presented] Conclusion: On the basis of this meta-analysis, the use of clopidogrel may be favored over ticagrelor or prasugrel in patients with AF on OAC undergoing PCI