Anticoagulation and Antiplatelet Therapy for Atrial Fibrillation and Stable Coronary Disease: Meta-Analysis of Randomized Trials.

Summary

Pooling four RCTs (n=4,092), OAC monotherapy reduced major bleeding (HR 0.59) versus OAC+single antiplatelet without increasing ischemic events or mortality. Results support OAC alone for AF with stable CAD beyond the acute coronary period.

Key Findings

• No significant difference in ischemic composite outcomes between OAC monotherapy and OAC+SAPT (HR 0.90).
• Major bleeding significantly lower with OAC monotherapy (3.3% vs 5.7%; HR 0.59).
• Findings consistent across subgroups; exploratory signal suggests greater bleeding reduction in men.

Clinical Implications

In AF with stable CAD beyond the early post-ACS/PCI phase, prefer OAC monotherapy to minimize bleeding; reserve antiplatelet therapy for compelling coronary indications.

Limitations

• Only four RCTs; some were not powered for individual effectiveness endpoints
• Heterogeneity in OAC agents, SAPT use, and follow-up durations

Future Directions

Head-to-head trials or IPD meta-analyses stratifying by coronary complexity, time from PCI, and bleeding risk to refine patient-level recommendations.