We read the meta-analysis by Fabrizio D′ Ascenzo et al that compared the various antithrombotic and antiplatelet regimens in patients receiving oral anticoagulants (OACs) who underwent percutaneous coronary intervention (PCI). We commend the investigators on their work. We believe the following issues should be clarified:

• 1.
  

  The meta-analysis did not mention the average duration of triple therapy (TT) which is an important information and vital for making a clinical decision. Moreover, in certain studies, for example, Ruiz-Nodar et al, there was no consistency in the duration of TT. Therefore, Ruiz-Nador et al subdivided patients into anticoagulated and not anticoagulated groups, which indicate that anticoagulated group included both TT and dual therapy. This study may affect the results of the meta-analysis.

  
  
• 2.
  

  The main focus of this meta-analysis is to compare various antithrombotic and antiplatelet regimens in patients receiving OAC who underwent PCI. However, review of the included studies showed that certain studies, for example, Lambarts et al, included patients with atrial fibrillation hospitalized with myocardial infarction (MI) and/or who underwent PCI. We believe this study may need to be excluded or other studies that had patients with MI should be included.

  
  
• 3.
  

  Certain important patients’ characteristics are missing including CHADS2, CHADSVASC, and HASBLED scores in each of the included studies. The outcome may be different if we stratify patients based on the aforementioned scores.

  
  
• 4.
  

  It is established in the literature that OAC reduces the incidence of stroke in patients with atrial fibrillation. The author reported composite all-cause mortality, MI, stent thrombosis, and stroke as a secondary outcome. The results suggested no significant difference between dual antiplatelet therapy and TT in the secondary outcome, but the evidence was weak. If the secondary outcome components were analyzed separately, will the risk of stroke be higher in dual antiplatelet therapy compared with TT?

In conclusion, management of patients on chronic OAC who underwent PCI is challenging. The impact of these different treatment approaches on cardiovascular mortality, bleeding, and other adverse outcomes are difficult to assess in observation studies, and a large randomized trial with long-term follow-up is needed.