The Efficacy and Safety of Triple Antithrombotic versus Dual Antiplatelet for Acute Coronary Syndrome without Atrial Fibrillation: A Meta-analysis

BACKGROUND Acute Coronary Syndrome (ACS) remains as one the leading cause of morbidity and mortality. Several randomized clinical trials have shown the efficacy of direct oral anticoagulants (DOACs) on top of dual-antiplatelet therapy (DAPT) among patients with recent ACS but have shown increased bleeding risk. However, there have been newer studies which showed lower risk for bleeding. Hence, this meta-analysis will look into the efficacy and safety of triple antithrombotic therapy (TAT), DAPT plus DOAC, among patients with recent ACS without Atrial Fibrillation (AF). METHODOLOGY This study used a random-effects meta-analysis using RevMan 5.4. The risk of bias was assessed using Cochrane RoB2 and the certainty of evidence was assessed using GRADE. RESULTS This meta-analysis showed that, when analyzed overall, TAT when compared to DAPT reduced the risk of composite MACE (RR 0.88, 95% CI 0.81-0.96) and myocardial infarction (MI) (RR 0.88, CI 0.78-0.98) with a significant risk for any (RR 1.9, 95% CI 1.32-2.74) and major bleeding (RR 2.26, 95% CI 1.47-3.48). When analyzed using the lowest dose, TAT had no significant benefit in reducing risk of composite MACE (RR 0.90, 95% CI 0.82-1.00) and MI (RR 0.93, 95% CI 0.81-1.05) but still poses significant risk for any (RR 1.57, 95% CI 1.18-2.10) and major bleeding (RR 2.28, 95% CI 1.45-3.60). CONCLUSION Among patients with recent ACS without AF, TAT at best modestly reduces the risk for composite MACE and myocardial infarction but poses a significant risk for bleeding when compared to DAPT. Further studies have to be made using the newer agents with larger populations to ascertain the value of TAT in ACS without AF.