Oral anticoagulant (OAC) monotherapy vs. dual-antithrombotic therapy (DAT) in patients with atrial fibrillation and coronary artery disease; a meta-analysis of four randomized controlled trials

Background: Dual-antithrombotic therapy (DAT) is recommended for patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) but carries an increased risk of bleeding. Recent trials suggest oral anticoagulant (OAC) monotherapy as a safer alternative, but data remains limited. We conducted a meta-analysis to compare OAC monotherapy with DAT in this population. Methods: A comprehensive literature search was conducted using PubMed, Embase, and Cochrane Central Library to identify randomized controlled trials (RCTs) that compared OAC monotherapy with DAT in patients with AF and stable CAD. A bivariate random-effects model was used to perform meta-analyses. Statistical analyses were conducted using R Software 4.4.1, with a significance level of P < 0.05. Heterogeneity was assessed using I-2 statistics, and the quality of studies was evaluated using the revised Cochrane risk-of-bias tool. Results: Four RCTs with a total of 4123 patients (20.2% females) were included. The mean age of the participants was 74 years. The results showed a significant reduction in major or clinically relevant nonmajor bleeding (risk ratio [RR]: 0.52; 95% confidence interval [CI]: 0.34-0.80; P = 0.003) in the OAC monotherapy group compared to the DAT group. However, net adverse clinical events (NACE) (RR: 0.67; 95% CI: 0.45-1.01; P = 0.054), major ischemic events (RR: 0.98; 95% CI: 0.62-1.53; P = 0.91) and all-cause mortality (RR: 0.94; 95% CI: 0.49-1.83; P = 0.87) were comparable between the two groups. Conclusions: In patients with AF and stable CAD, OAC monotherapy reduced the risk of major bleeding, with no significant differences in NACE, major ischemic events, or all-cause mortality as compared to DAT.