Mohsen Safari, Zeinab Safari
Coronary artery ectasia (CAE) is a rare vascular anomaly characterized by abnormal dilation of coronary arteries. This predisposes patients to thrombotic events and ischemic heart disease (IHD) due to turbulent flow and stasis. While antiplatelet therapy has been the cornerstone of management, anticoagulants are increasingly advocated to mitigate thrombus formation in ectatic segments. We conducted a PRISMA compliant search of PubMed, Google Scholar, and Cochrane Library up to 2025, using terms like "coronary artery ectasia," "anticoagulant therapy," and "ischemic heart disease." Included were peer reviewed studies comparing anticoagulants (warfarin or Direct oral anticoagulants (DOACs)) to antiplatelets in CAE patients, reporting IHD outcomes. Data extraction focused on study design, demographics, interventions, and endpoints; quality was assessed via Cochrane Risk of Bias and Newcastle Ottawa Scale. Random effects meta analysis calculated risk ratios (RR) with 95% confidence intervals (CI); heterogeneity via I². Subgroups analyzed anticoagulant type and CAE etiology. 13 studies (n = 5,700 patients) were included. Anticoagulants reduced IHD risk (RR = 0.72, 95% CI = 0.64 0.81; P < 0.001; I² =47%), with DOACs showing greater efficacy (RR = 0.65, 95% CI = 0.54 0.79) than warfarin (RR = 0.82, 95% CI = 0.70 0.96). Major bleeding was higher with anticoagulants (RR = 1.45, 95% CI = 1.20 1.75; P < 0.01), but lower for DOACs versus warfarin. No mortality difference (RR = 0.98, 95% CI = 0.86 1.12; P = 0.74). Anticoagulants, particularly DOACs, offer superior IHD prevention in CAE but increase bleeding risk. Personalized therapy is recommended.