Systematic Review and Meta-analysis of Dual Versus Single Antiplatelet Therapy in Carotid Interventions

Background: The importance of antiplatelet therapy for the management and prevention of ischaemic stroke cannot be overstated. Despite the established guidelines, there is no clear consensus on how to manage antiplatelet therapy during and after carotid interventions. Objective: The objective was to undertake a systematic literature review and perform a meta-analysis to assess the effects of dual antiplatelet therapy in carotid endarterectomy (CEA) and stenting (CAS). Data sources: Electronic information sources (MEDLINE, EMBASE, CINAHL, CENTRAL) and bibliographic reference lists were searched to identify randomised controlled trials (RCTs) and observational studies reporting comparative outcomes of dual versus single antiplatelet therapy in CEA and CAS. Methods: Primary outcomes were mortality and stroke within 30 days of intervention. Secondary outcomes were transient ischaemic attack (TIA), major bleeding, groin or neck haematoma, and myocardial infarction (MI). Dichotomous outcome measures were reported using the risk difference (RD) and 95% confidence interval (Cl). Combined overall treatment effects were calculated using fixed-effect or random-effects models. Results: Three RCTs and seven observational studies were identified reporting a total of 36,881 CEAs and 150 CAS procedures. In CEA, there were no differences in stroke/TIA/death between single and dual antiplatelet therapy, but there was a significant risk of major bleeding (RD, 0.00; 95% Cl, 0.00-0.01; p=.0003) and neck haematoma with dual therapy (RD, 0.04; 95% Cl, 0.01-0.06; p=.001). In addition, the rate of MI was higher in the dual therapy group than the single therapy group (RD, 0.00; 95% Cl, 0.00-0.01; p=.003). In CAS, there was no difference in major bleeding or haematoma formation, but a significant difference in TIA in favour of dual therapy was identified (RD -0.13, 95% CI, -0.22 to -0.05; p=.003). Conclusions: Dual antiplatelet therapy demonstrates advantages over single therapy only in CAS, as indicated by a reduced risk of TIA. Dual antiplatelet therapy was associated with an increased risk of bleeding complications in patients undergoing CEA. (C) 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.