<p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">Anticoagulation monotherapy alone may cut bleeding and cardiovascular death without increasing ischemic events in patients with chronic coronary syndrome (CCS) and atrial fibrillation (AF), new meta-analysis data shows.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">The study, published online in <i>JACC: Cardiovascular Interventions</i>, pooled data from 5,924 patients requiring long-term oral anticoagulation (OAC) in 6 randomized trials, including newer data from the AQUATIC and ADAPT AF-DES trials that was not included in previous meta-analyses.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">Led by Mattia Galli, MD, PhD, of Sapienza University in Rome, the researchers noted that while clinical guidelines recommend anticoagulation alone, many patients continue a single antiplatelet agent as well.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">The analysis reported that for major adverse cardiovascular events (MACE), there was no statistical difference between the two strategies. However, Galli and colleagues noted that monotherapy roughly halved the risk of any bleeding, and significantly reduced cardiovascular death — a first for this type of analysis.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">"These findings reinforce current guideline recommendations supporting OAC monotherapy as the preferred long-term antithrombotic strategy for patients with AF and stable CAD," the authors wrote, adding that treatment decisions should remain individualized given each patient's residual risk.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><b><span lang="EN">Study details<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">The included trials compared OAC monotherapy with OAC plus a single antiplatelet agent over a median 2.3 years. Patients carried a high stroke risk, with a median CHA2DS2-VASc score of 4.2. Most had previously undergone revascularization, with a median 3.8 years between revascularization and randomization.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">The primary efficacy endpoint was trial-defined MACE, and the primary safety endpoint was any bleeding. Secondary endpoints included cardiovascular death, net adverse clinical events, major bleeding, myocardial infarction, stroke and all-cause death.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">Galli and colleagues reported that the primary efficacy endpoint, MACE, occurred in 6.8% of patients on monotherapy and 8.2% on combination therapy, a difference that fell short of significance (hazard ratio [HR]: 0.85; 95% CI: 0.66-1.09).<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">However, the safety endpoint of any bleeding occurred in 8.9% on monotherapy versus 16.1% on combination therapy (HR: 0.49; 95% CI: 0.44-0.55), they said, noting a number needed to treat of just 13. <o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">Both the high certainty of the evidence and a trial sequential analysis marked the benefit as conclusive, the authors stated.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">Among secondary outcomes, monotherapy reduced cardiovascular death by nearly a third (HR: 0.69; 95% CI: 0.48-0.97), with parallel reductions in net adverse clinical events (HR: 0.60; 95% CI: 0.47-0.78) and major bleeding (HR: 0.46; 95% CI: 0.32-0.66).<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">No harm signal emerged, the researchers added, noting that myocardial infarction (HR: 1.05; 95% CI: 0.59-1.89), stroke (HR: 0.92; 95% CI: 0.63-1.33) and all-cause death (HR: 0.77; 95% CI: 0.53-1.13) were no different between the groups.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><b><span lang="EN">Still room for combination therapy?<o:p></o:p></span></b></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">Galli and colleagues cautioned that the results apply mainly to patients resembling those enrolled in the trials — predominantly East Asian men at high ischemic risk, most of whom had undergone percutaneous coronary intervention (PCI) several years before randomization — adding that how well the findings extend to women, older adults, non-East Asian populations or patients after complex PCI remains uncertain.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">They added that the question of which patients might still warrant extended combination therapy also remains open, noting that ongoing trials such as ADONIS-PCI and WOEST-3 may help.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">For now, decisions should weigh time since PCI and residual high-risk features case by case, the authors wrote.<b><o:p></o:p></b></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><b><span lang="EN">Source:</span></b><span lang="EN"> <o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><span lang="EN">Galli M, Vinciguerra M, Laudani C, et al. Oral Anticoagulation With or Without Antiplatelet Therapy in Chronic Coronary Syndrome: A Meta-Analysis of Randomized Trials. <i>JACC: Cardiovasc Interv</i>. 2026;19(10):1294-1306.<o:p></o:p></span></p> <p class="MsoNormal" style="margin: 12.0pt 0in 12.0pt 0in;"><b><span lang="EN">Image Credit: nito – stock.adobe.com<o:p></o:p></span></b></p>