Journal of the American College of Cardiology ( IF 24.0 ) Pub Date : 2021-07-15 , DOI: 10.1016/j.jacc.2021.06.012 Satoshi Shoji 1 , Toshiki Kuno 2 , Tomohiro Fujisaki 3 , Hisato Takagi 4 , Alexandros Briasoulis 5 , Pierre Deharo 6 , Thomas Cuisset 6 , Azeem Latib 7 , Shun Kohsaka 1
Background
Balancing the effects of dual antiplatelet therapy (DAPT) in the era of potent P2Y12 inhibitors has become a cornerstone of acute coronary syndrome (ACS) management. Recent randomized controlled trials (RCTs) have investigated DAPT de-escalation to decrease the risk of bleeding outcomes.
Objectives
The aim of this study was to compare the efficacy and safety outcomes of various DAPT strategies in patients with ACS, including de-escalation from a potent P2Y12 inhibitor to clopidogrel or low-dose prasugrel.
Methods
MEDLINE and EMBASE were searched through January 2021 for RCTs investigating the efficacy and safety of DAPT in patients with ACS, and a network meta-analysis was conducted. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, and stroke. The primary bleeding outcome was trial-defined major or minor bleeding.
Results
Our search identified 15 eligible RCTs, including 55,798 patients with ACS. De-escalation therapy was associated with reduced risk of primary bleeding outcomes (HR: 0.48 [95% CI: 0.30-0.77] vs clopidogrel; HR: 0.32 [95% CI: 0.20-0.52] vs ticagrelor; HR: 0.36 [95% CI: 0.24-0.55] vs standard-dose prasugrel; and HR: 0.40 [95% CI: 0.22-0.75] vs low-dose prasugrel) without negatively affecting primary efficacy outcomes. There were no significant differences in ischemic or bleeding outcomes between de-escalation to clopidogrel or low-dose prasugrel.
Conclusions
Compared with other established uses of DAPT, de-escalation was the most effective strategy for ACS treatment, resulting in fewer bleeding events without increasing ischemic events.
中文翻译:
急性冠脉综合征患者双联抗血小板治疗的降级
背景
在强效 P2Y 12抑制剂时代平衡双重抗血小板治疗 (DAPT) 的效果已成为急性冠状动脉综合征 (ACS) 管理的基石。最近的随机对照试验 (RCT) 研究了 DAPT 降级以降低出血风险。
目标
本研究的目的是比较各种 DAPT 策略在 ACS 患者中的疗效和安全性结果,包括从强效 P2Y 12抑制剂降级为氯吡格雷或低剂量普拉格雷。
方法
检索了截至 2021 年 1 月的 MEDLINE 和 EMBASE,以寻找研究 DAPT 在 ACS 患者中的疗效和安全性的 RCT,并进行了网络荟萃分析。主要疗效结局是心血管死亡、心肌梗死和卒中的复合结局。主要出血结局是试验定义的大出血或小出血。
结果
我们的搜索确定了 15 项符合条件的 RCT,包括 55,798 名 ACS 患者。降阶梯治疗与降低主要出血结局的风险相关(HR:0.48 [95% CI:0.30-0.77] vs 氯吡格雷;HR:0.32 [95% CI:0.20-0.52] vs 替格瑞洛;HR:0.36 [95% CI:0.24-0.55] vs 标准剂量普拉格雷;HR:0.40 [95% CI:0.22-0.75] vs 低剂量普拉格雷),而不会对主要疗效结果产生负面影响。降级至氯吡格雷或低剂量普拉格雷的缺血或出血结局无显着差异。
结论
与 DAPT 的其他既定用途相比,降级是 ACS 治疗的最有效策略,可减少出血事件而不会增加缺血事件。