Oral Anticoagulant Monotherapy Versus Combination Therapy in Patients With Chronic Coronary Syndrome: A Systematic Review and Meta-analysis of Randomized Trials
In brief
Oral anticoagulant alone cuts net adverse events by ~40% in chronic coronary syndrome
A meta-analysis of five randomized trials (5,777 patients) found that using oral anticoagulant monotherapy, instead of adding a single antiplatelet, lowered the combined risk of death, heart attack, stroke and major bleeding by about 40% and halved major bleeding. Ischemic outcomes were similar, suggesting a safer strategy without clear loss of protection.
- Journal
- European journal of preventive cardiology (Q1)
- Published
- 11 August 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Anastasios Tsarouchas, David Mutschlechner, Maximilian Tscharre, Christodoulos E Papadopoulos, Thomas Gremmel
- PMID
- 42576699
- DOI
- 10.1093/eurjpc/zwag416
Why clinicians should know about it
- Picked for Cardiology and Cardiovascular Medicine (top studies of the week, 16 August 2026): Meta‑analysis shows OAC monotherapy reduces bleeding in CCS
- Picked for Epidemiology (top studies of the week, 16 August 2026).
Abstract
AIMS: In patients on long-term oral anticoagulation (OAC), the optimal antithrombotic strategy in the setting of concomitant chronic coronary syndrome (CCS) remains unclear. We therefore performed a systematic review and meta-analysis of randomized controlled trials comparing OAC monotherapy versus OAC plus single antiplatelet therapy (combination therapy) in patients with CCS and any indication for long-term OAC.. METHODS: We systematically searched PubMed/MEDLINE and Embase through February 2026 to identify trials randomizing CCS patients with an indication for long-term OAC to OAC monotherapy vs. combination therapy. Net adverse clinical events (NACE) were defined as primary composite endpoint. Key secondary outcomes included major adverse cardiovascular events (MACE), major bleeding, and major or clinically relevant non-major bleeding. Hazard ratios (HRs) were pooled using Bayesian random-effects models. RESULTS: Six (6) randomized trials met the inclusion criteria. Five (5) contributed to quantitative synthesis of primary and main secondary outcome measures (5,777 participants). OAC monotherapy significantly reduced NACE (HR 0.61, 95% CrI 0.43-0.85), major bleeding (HR 0.47, 95% CrI 0.30-0.71) and major or clinically relevant non-major bleeding (HR 0.47, 95% CrI 0.31-0.66) compared to combination therapy. No significant differences were observed for MACE (HR 0.83, 95% CrI 0.60-1.18), cardiovascular death (HR 0.70, 95% CrI 0.44-1.13), all-cause death, unplanned revascularisation, myocardial infarction and ischemic stroke. Prespecified subgroup analyses for NACE and MACE outcomes detected a signal of lower risk of MACE with direct oral anticoagulant monotherapy compared to monotherapy with vitamin K antagonists (p=0.02). CONCLUSIONS: In CCS patients on OAC, OAC monotherapy reduces bleeding events compared to combination therapy, without clear evidence of a concomitant increase in ischemic risk.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.