(Adapted from Angiolillo et al.202 ) 1168 Evidence-Based Medicine [ 1 5 4 # 5 C H E S T N O V E M B E R 2 0 1 8 ] In a systematic review and meta-analysis (18 studies with 20,456 patients with AF; 7,203 patients received DAPT VKA and 13,253 patients received DAPT after PCI/stenting), Chaudhary et al280 showed that DAPT and VKA were associated with signi cantly lower risk of stroke, stent thrombosis, and all-cause mortality, but the risk of major bleeding was signi cantly higher in the DAPT and VKA group. Broadly similar conclusions were drawn from the systematic review and meta-analysis (17 studies, 104,639 patients) by Zhu et al281 where triple therapy (DAPT OAC) was associated with an increased risk of bleeding compared with DAPT alone, with no differences observed between triple therapy and the dual therapy for all-cause death, cardiovascular death, or thrombotic complications (ie, ACS, stent thrombosis, thromboembolism/stroke, and major adverse cardiac and cerebrovascular events). In both systematic reviews, there was marked heterogeneity in study size, patient population, intervention types, stent use, etc. Bennaghmouch et al282 reported a meta-analysis restricted to the subgroups of patients on aspirin therapy (n 21,722) from the 4 RCTs comparing VKA and NOACs (N 71,681) in AF patients. NOACs were more effective (outcome stroke or systemic embolism HR, 0.78 [95% CI, 0.67-0.91] and vascular death HR, 0.85 [95% CI, 0.76-0.93]) and as safe as VKA with respect to major bleeding (HR, 0.83 [95% CI, 0.69- 1.01]). NOACs were safer with respect to the reduction of ICH (HR, 0.38 [95% CI, 0.26-0.56]). Thus, it may be both safer and more effective to use NOACs compared with VKAs to treat patients with nonvalvular AF and concomitant aspirin therapy. 