Direct oral anticoagulants combined with antiplatelet in the treatment of acute coronary syndrome and atrial fibrillation patients undergoing percutaneous coronary intervention or complicating acute coronary syndrome: a systematic review and meta-analysis

The study aimed to comprehensively evaluate the role of direct oral anticoagulants (DOACs) combined with antiplatelet therapy (APT) in acute coronary syndrome (ACS) patients and those with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) or complicating ACS. Data were pooled using the Mantel – Haenszel random-effect models. The risk ratio (RR) value and 95% confidence intervals (CI) calculated were applied to dichotomous outcomes. In 38,170 ACS patients from 11 studies, DOACs combined with APT significantly reduced major adverse cardiovascular events (MACEs), stent thrombosis (ST), ischemic stroke and all-cause death, accompanied by increased bleeding risks compared with control groups. Among 11,175 participants from 6 studies involving AF patients undergoing PCI or complicating ACS, DOACs plus APT markedly reduced bleeding risksin various definitions, with no significant difference in efficacy outcomes compared with control groups. The combination of DOACs and APT requires a tailored approach. For ACS patients, therapy should center on balancing ischemic and bleeding risks, favoring those at high ischemic risk but low or manageable bleeding risk. In contrast, for AF patients undergoing PCI or complicating ACS, the regimen is aimed at risk minimization and is most suitable for patients in whom this is the primary concern. Protocol registration: .uk/prospero identifier is CRD42025645639.http://www.crd.york.ac