Introduction

We aimed to evaluate the clinical benefits of a de-escalation strategy from prasugrel or ticagrelor to clopidogrel versus continuation of prasugrel or ticagrelor along with aspirin in both strategies for patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI), and to analyze the effect of the recently published randomized clinical trial (RCT) by Park et al., which included the largest sample size ever and the largest switched number of patients, on current guidelines and practices.

Data Sources

The PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar databases were searched systematically from inception to May 2021 by using the search terms (‘de-escalation’ OR ‘switching’) AND (‘antiplatelet’ OR ‘clopidogrel’ OR ‘ticagrelor’ OR ‘prasugrel’) AND (‘percutaneous coronary intervention’ OR ‘PCI’' OR ‘Acute coronary syndrome’ OR ‘ACS’).

Study Selection and Data Extraction

We included RCTs that reported the primary outcomes, i.e. net clinical benefits and Bleeding Academic Research Consortium (BARC) type 2 or higher bleeding. A combination of both ischemic and bleeding events was defined as a net clinical benefit.

Data Synthesis

A total of four RCTs were included, with 5952 patients. A random-effects meta-analysis revealed that a de-escalation strategy was associated with lower ischemic and bleeding events (net clinical benefits; risk ratio [RR] 0.63, 95% confidence interval [CI] 0.47–0.85; p = 0.003), and lower BARC type 2 or higher bleeding (RR 0.51, 95% CI 0.29–0.91; p = 0.02) when compared with a continuation strategy.

Relevance to Patient Care and Clinical Practice

The current guidelines recommend potent P2Y12 prasugrel or ticagrelor for 12 months despite their association with a high risk of bleeding. Our meta-analysis updates cardiologists, providing them with the best available evidence in managing patients with ACS who underwent PCI.

Conclusion

Among patients with ACS treated with PCI, a de-escalation strategy (prasugrel or ticagrelor to clopidogrel) is associated with lower ischemic and bleeding events (net clinical benefits) and lower BARC type 2 or higher bleeding; however, due to the limited number of included studies, further high-quality studies are needed to establish the clinical efficacy of the de-escalation strategy.

中文翻译：

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经皮冠状动脉介入治疗的急性冠状动脉综合征患者从普拉格雷或替格瑞洛降级至氯吡格雷：随机临床试验的最新荟萃分析

介绍

我们旨在评估从普拉格雷或替格瑞洛降级策略到氯吡格雷与继续普拉格雷或替格瑞洛联合阿司匹林在急性冠状动脉综合征 (ACS) 和经皮冠状动脉介入治疗 (PCI) 治疗的两种策略中的临床益处，并分析 Park 等人最近发表的随机临床试验 (RCT) 对当前指南和实践的影响，该试验包括有史以来最大的样本量和最大的患者转换数量。

数据源

PubMed、EMBASE、Scopus、Web of Science、Cochrane Central 和 Google Scholar 数据库从开始到 2021 年 5 月进行了系统搜索，使用搜索词（“降级”或“转换”）和（“抗血小板”或“氯吡格雷” '或'替格瑞洛'或'普拉格雷'）和（'经皮冠状动脉介入治疗'或'PCI''或'急性冠状动脉综合征'或'ACS'）。

研究选择和数据提取

我们纳入了报告主要结果的随机对照试验，即净临床获益和出血学术研究联盟 (BARC) 2 型或更高的出血。缺血和出血事件的组合被定义为净临床获益。

数据综合

共纳入四项随机对照试验，5952 名患者。随机效应荟萃分析显示，降级策略与较低的缺血和出血事件相关（净临床获益；风险比 [RR] 0.63，95% 置信区间 [CI] 0.47–0.85；p  = 0.003），与继续策略相比，BARC 2 型或更高出血率更低（RR 0.51, 95% CI 0.29–0.91；p  = 0.02）。

与患者护理和临床实践的相关性

目前的指南推荐强效 P2Y12 普拉格雷或替格瑞洛 12 个月，尽管它们与高出血风险相关。我们的荟萃分析更新了心脏病专家，为他们提供了管理接受 PCI 的 ACS 患者的最佳可用证据。

结论

在接受 PCI 治疗的 ACS 患者中，降级策略（普拉格雷或替格瑞洛改为氯吡格雷）与较低的缺血和出血事件（净临床获益）和较低的 BARC 2 型或更高出血相关；然而，由于纳入的研究数量有限，需要进一步的高质量研究来确定降级策略的临床疗效。