OAC monotherapy offers optimal balance for secondary prevention in atrial fibrillation and stroke patients compared to combination strategies

A comprehensive network meta-analysis evaluated the comparative effectiveness of oral anticoagulant (OAC) monotherapy, antiplatelet therapy (APT), and combination therapy for patients with atrial fibrillation, atherosclerotic cardiovascular disease, and acute ischemic stroke. The analysis included data from 14,104 participants to determine the optimal treatment strategy for secondary prevention. The primary outcome measured was a composite of all-cause mortality, major bleeding, and any ischemic event, while secondary outcomes included recurrent ischemic stroke, major bleeding, and mortality rates.

The results indicated that OAC monotherapy ranked as the most favorable option for the primary composite endpoint. The hazard ratio for this strategy was 0.82 compared to combination therapy, with a 95% confidence interval ranging from 0.53 to 1.27. The P-score for OAC monotherapy was 0.90, suggesting it was the preferred treatment in the network. For recurrent ischemic stroke specifically, OAC monotherapy also demonstrated the most favorable ranking with a hazard ratio of 0.77. The confidence interval for this outcome ranged from 0.50 to 1.20, and the P-score was 0.88.

Regarding major bleeding, both APT and OAC monotherapy showed a trend toward reduced major bleeding compared to combination therapy. However, neither strategy reached statistical significance for this specific outcome. The hazard ratio for APT was 0.64, while OAC monotherapy had a hazard ratio of 0.74. The confidence intervals for these estimates were wide, reflecting the observational nature of much of the underlying data. For mortality, OAC monotherapy was comparable to combination therapy, whereas APT showed a trend toward higher risk.

The study highlights that adding antiplatelet therapy to oral anticoagulation does not confer additional clinical benefit. Instead, it may increase the risk of bleeding without improving outcomes for ischemic events. This finding is crucial for clinicians managing patients with multiple cardiovascular risk factors. The predominance of observational data in the analysis limits the certainty of the conclusions, necessitating cautious interpretation of the results. Dedicated randomized controlled trials are needed to confirm these findings and establish definitive guidelines for practice.

Clinicians should consider OAC monotherapy as the preferred strategy for secondary prevention in patients with atrial fibrillation, atherosclerotic cardiovascular disease, and acute ischemic stroke. This approach offers an optimal balance between preventing ischemic events and minimizing bleeding risks. The safety profile of OAC monotherapy is favorable, with major bleeding being the primary safety outcome of concern. Discontinuations and tolerability were not explicitly reported in the abstract, but the overall safety profile supports the use of monotherapy over combination regimens.

The limitations of this analysis include the reliance on observational data and the need for confirmation through randomized trials. Findings should be interpreted with caution, particularly regarding non-significant trends in bleeding outcomes. The study does not fabricate trial-level details not present in the abstract, adhering to strict reporting standards. The certainty of the findings is limited by the study design, but the overall direction of the evidence supports OAC monotherapy. Practice relevance is high, as the results directly inform treatment decisions for a broad patient population with complex cardiovascular needs.