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Herron GC, Bates ER. Review of the Ticagrelor Trials Evidence Base. J Am Heart Assoc 2024; 13:e031606. [PMID: 38804216 DOI: 10.1161/jaha.123.031606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Ticagrelor is a platelet P2Y12 receptor inhibitor approved for use in patients with acute coronary syndromes, coronary artery disease, and low-moderate risk acute ischemic stroke or high-risk transient ischemic attack. Clinical trials have evaluated the efficacy and safety of ticagrelor on ischemic and bleeding outcomes for different indications and with varying treatment approaches. As a result, there is a large body of clinical evidence demonstrating different degrees of net clinical benefit compared with other platelet inhibitor drugs based on indication, patient characteristics, clinical presentation, treatment duration, and other factors. We provide a review of the major trials of ticagrelor in the context of other randomized trials of clopidogrel and prasugrel to organize the volume of available information, elevate corroborating and conflicting data, and identify potential gaps as areas for further exploration of optimal antiplatelet treatment.
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Affiliation(s)
| | - Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine University of Michigan Ann Arbor MI USA
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Shoji S, Kuno T, Ueyama H, Takagi H, Briasoulis A, Kim HS, Koo BK, Kang J, Watanabe H, Kimura T, Kohsaka S. Preferred monotherapy after short-term dual antiplatelet therapy: Systematic review and network meta-analysis of randomized trials. J Cardiol 2024; 83:338-347. [PMID: 37562542 DOI: 10.1016/j.jjcc.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Randomized controlled trials (RCTs) have demonstrated the efficacy and safety of P2Y12 inhibitor monotherapy following short-term dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI). However, no studies have compared P2Y12 inhibitor and aspirin monotherapy following short-term DAPT. We aimed to compare available strategies for DAPT duration and post-DAPT antiplatelet monotherapy following PCI. METHODS Seven DAPT strategies [ticagrelor or clopidogrel following 1-month DAPT, ticagrelor following 3-month DAPT, aspirin following 3-6 months of DAPT (reference strategy), aspirin or P2Y12 inhibitor following 6-18-months of DAPT, and DAPT for ≥18 months] were compared using a network meta-analysis. The primary efficacy outcome was defined as a composite of all-cause death, myocardial infarction, and stroke. The primary bleeding outcome was trial-defined major or minor bleeding. RESULTS Our analysis identified 25 eligible RCTs, including 89,371 patients who underwent PCI. Overall, none of the strategies negatively affected the primary efficacy outcomes. For primary bleeding outcomes, ticagrelor following 3-month DAPT was associated with a reduced risk of primary bleeding outcomes (HR 0.73; 95 % CI 0.57-0.95). Clopidogrel following 1-month DAPT was also associated with a reduced risk of primary bleeding outcomes (HR 0.54; 95 % CI 0.34-0.85), however, the strategy was associated with an increased risk of myocardial infarction or stent thrombosis. Similar trends were observed among patients with acute coronary syndrome and high bleeding risk. CONCLUSIONS Compared with aspirin monotherapy following short-term DAPT, ticagrelor following 3-month DAPT was associated with a reduced risk of primary bleeding outcomes without increasing any ischemic outcomes.
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Affiliation(s)
- Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan; Duke Clinical Research Institute, Durham, NC, USA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA.
| | - Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA; Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Alexandros Briasoulis
- Division of Cardiology, Heart Failure and Transplantation, University of Iowa, Iowa City, IA, USA
| | - Hyo-Soo Kim
- Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Bon-Kwon Koo
- Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Jeehoon Kang
- Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | | | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Tasoudis PT, Kyriakoulis IG, Sagris D, Diener HC, Ntaios G. Clopidogrel Monotherapy versus Aspirin Monotherapy in Patients with Established Cardiovascular Disease: Systematic Review and Meta-Analysis. Thromb Haemost 2022; 122:1879-1887. [PMID: 35577054 DOI: 10.1055/a-1853-2952] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND There is no clear consensus on whether aspirin offers better outcomes in terms of secondary cardiovascular disease prevention compared with clopidogrel. OBJECTIVE The aim of the study was to compare the safety and efficacy of clopidogrel versus aspirin in patients with established cardiovascular disease. METHODS A systematic review of MEDLINE (via PubMed), Scopus, and Cochrane Library databases (last search date: August 28, 2021) was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement for randomized control trials (RCTs) of clopidogrel versus aspirin as monotherapy in patients with established cardiovascular disease. Random-effects meta-analyses were performed. RESULTS Five RCTs incorporating 26,855 patients (clopidogrel: 13,426; aspirin: 13,429) were included. No statistically significant difference was observed between clopidogrel and aspirin in terms of all-cause mortality (odds ratio [OR]: 1.01 [95% confidence interval, CI: 0.91-1.13]; p = 0.83), ischemic stroke (OR: 0.87 [95% CI: 0.71-1.06]; p = 0.16), and major bleeding rates (OR: 0.77 [95% CI: 0.56-1.06]; p = 0.11). Patients receiving clopidogrel had borderline lower risk for major adverse cardiovascular events (MACE) (OR: 0.84 [95% CI: 0.71-1.00]; p = 0.05) and lower risk for nonfatal myocardial infarction (OR: 0.83 [95% CI: 0.71-0.97]; p = 0.02, relative risk reduction = 16.9%, absolute risk reduction = 0.5%, number needed to treat = 217 for a mean period of 20 months) compared with patients receiving aspirin. CONCLUSION In patients with established cardiovascular disease, clopidogrel was associated with a 17% relative-risk reduction for nonfatal MI, borderline decreased risk for MACE, and similar risk for all-cause mortality, stroke, and major bleeding compared with aspirin. PROTOCOL REGISTRATION PROSPERO CRD42021283866.
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Affiliation(s)
- Panagiotis T Tasoudis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Ioannis G Kyriakoulis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios Sagris
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Challenges of long-term dual antiplatelet therapy use following acute coronary syndromes. Am Heart J 2022; 246:44-64. [PMID: 34933000 DOI: 10.1016/j.ahj.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/24/2021] [Accepted: 12/15/2021] [Indexed: 11/20/2022]
Abstract
An acute coronary syndrome (ACS) event is associated with a high risk of recurrent ACS, stroke, and death. To ameliorate the risk of subsequent events, current guidelines for ST-segment elevation myocardial infarction and non-ST-segment elevation ACS recommend long-term management strategies for secondary prevention including risk factor modification and anti-ischemic and antiplatelet therapies. Dual antiplatelet therapy (DAPT), comprising aspirin plus a P2Y12 inhibitor, is a critical component of secondary prevention therapy following ACS. However, despite the importance of DAPT for secondary prevention after ACS, questions remain over the optimal duration of therapy. Clinical evidence is emerging that maintenance DAPT >12 months lowers the risk of recurrent ACS events; however, this benefit must be considered against any potential risks of prolonged DAPT such as bleeding. Several tools for bleeding risk assessment have shown promise; however, their limited accuracy and discriminative power necessitates further development. Assessment of patient ischemic risk should consider the complexity of the percutaneous coronary intervention (PCI) procedure, anatomic burden of coronary artery disease, and additional underlying risk factors. Consequently, identifying patients in whom the risk:benefit ratio favors prolonged DAPT may prove invaluable for clinicians in deciding which patients should continue or stop taking DAPT at 12 months after PCI, or consider P2Y12 inhibitor monotherapy as an option. This article reviews the most recent information about the risks and benefits of DAPT continued for >12 months after ACS and provides critical guidance to assist physicians in identifying patients most likely to benefit from a secondary prevention strategy with DAPT.
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Aggarwal D, Bhatia K, Chunawala ZS, Furtado RHM, Mukherjee D, Dixon SR, Jain V, Arora S, Zelniker TA, Navarese EP, Mishkel GJ, Lee CJ, Banerjee S, Bangalore S, Levisay JP, Bhatt DL, Ricciardi MJ, Qamar A. P2Y 12 inhibitor versus aspirin monotherapy for secondary prevention of cardiovascular events: meta-analysis of randomized trials. EUROPEAN HEART JOURNAL OPEN 2022; 2:oeac019. [PMID: 35919116 PMCID: PMC9242055 DOI: 10.1093/ehjopen/oeac019] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/13/2022] [Indexed: 12/24/2022]
Abstract
Aim To compare the efficacy and safety of P2Y12 inhibitor or aspirin monotherapy for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD). Methods and results Medline, Embase, and Cochrane Central databases were searched to identify randomized trials comparing monotherapy with a P2Y12 inhibitor versus aspirin for secondary prevention in patients with ASCVD (cardiovascular, cerebrovascular, or peripheral artery disease). The primary outcome was major adverse cardiac events (MACE). Secondary outcomes were myocardial infarction (MI), stroke, all-cause mortality, and major bleeding. A random-effects model was used to calculate risk ratios (RR) and the corresponding 95% confidence interval (CI) and heterogeneity among studies was assessed using the Higgins I2 value. A total of 9 eligible trials (5 with clopidogrel and 4 with ticagrelor) with 61 623 patients were included in our analyses. Monotherapy with P2Y12 inhibitors significantly reduced the risk of MACE by 11% (0.89, 95% CI 0.84-0.95, I2 = 0%) and MI by 19% (0.81, 95% CI 0.71-0.92, I2 = 0%) compared with aspirin monotherapy. There was no significant difference in the risk of stroke (0.85, 95% CI 0.73-1.01), or all-cause mortality (1.01, 95% CI 0.92-1.11). There was also no significant difference in the risk of major bleeding with P2Y12 inhibitor monotherapy compared with aspirin (0.94, 95% CI 0.72-1.22, I2 = 42.6%). Results were consistent irrespective of the P2Y12 inhibitor used. Conclusion P2Y12 inhibitor monotherapy for secondary prevention is associated with a significant reduction in atherothrombotic events compared with aspirin alone without an increased risk of major bleeding.
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Affiliation(s)
- Devika Aggarwal
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, MI, USA
| | - Kirtipal Bhatia
- Mount Sinai Heart, Mount Sinai Morningside Hospital, New York, NY, USA
| | | | - Remo H M Furtado
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.,Instituto do Coracao, Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Sau Paulo, Brazil
| | - Debabrata Mukherjee
- Division of Cardiology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Simon R Dixon
- Department of Cardiovascular Medicine, Beaumont Hospital Royal Oak, MI, USA
| | - Vardhmaan Jain
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Sameer Arora
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, USA
| | - Thomas A Zelniker
- Division of Cardiology, Vienna General Hospital and Medical University of Vienna, Austria
| | - Eliano P Navarese
- Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Gregory J Mishkel
- Division of Cardiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Cheong J Lee
- Division of Vascular Surgery, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | | | - Sripal Bangalore
- Department of Medicine (Cardiology), New York University Grossman School of Medicine, New York, NY, USA
| | - Justin P Levisay
- Division of Cardiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Deepak L Bhatt
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark J Ricciardi
- Division of Cardiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Arman Qamar
- Division of Cardiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Valgimigli M, Mehran R, Franzone A, da Costa BR, Baber U, Piccolo R, McFadden EP, Vranckx P, Angiolillo DJ, Leonardi S, Cao D, Dangas GD, Mehta SR, Serruys PW, Gibson CM, Steg GP, Sharma SK, Hamm C, Shlofmitz R, Liebetrau C, Briguori C, Janssens L, Huber K, Ferrario M, Kunadian V, Cohen DJ, Zurakowski A, Oldroyd KG, Yaling H, Dudek D, Sartori S, Kirkham B, Escaned J, Heg D, Windecker S, Pocock S, Jüni P. Ticagrelor Monotherapy Versus Dual-Antiplatelet Therapy After PCI: An Individual Patient-Level Meta-Analysis. JACC Cardiovasc Interv 2021; 14:444-456. [PMID: 33602441 DOI: 10.1016/j.jcin.2020.11.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/04/2020] [Accepted: 11/30/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to compare ticagrelor monotherapy with dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stents. BACKGROUND The role of abbreviated DAPT followed by an oral P2Y12 inhibitor after PCI remains uncertain. METHODS Two randomized trials, including 14,628 patients undergoing PCI, comparing ticagrelor monotherapy with standard DAPT on centrally adjudicated endpoints were identified, and individual patient data were analyzed using 1-step fixed-effect models. The protocol was registered in PROSPERO (CRD42019143120). The primary outcomes were the composite of Bleeding Academic Research Consortium type 3 or 5 bleeding tested for superiority and, if met, the composite of all-cause death, myocardial infarction, or stroke at 1 year, tested for noninferiority against a margin of 1.25 on a hazard ratio (HR) scale. RESULTS Bleeding Academic Research Consortium type 3 or 5 bleeding occurred in fewer patients with ticagrelor than DAPT (0.9% vs. 1.7%, respectively; HR: 0.56; 95% confidence interval [CI]: 0.41 to 0.75; p < 0.001). The composite of all-cause death, myocardial infarction, or stroke occurred in 231 patients (3.2%) with ticagrelor and in 254 patients (3.5%) with DAPT (HR: 0.92; 95% CI: 0.76 to 1.10; p < 0.001 for noninferiority). Ticagrelor was associated with lower risk for all-cause (HR: 0.71; 95% CI: 0.52 to 0.96; p = 0.027) and cardiovascular (HR: 0.68; 95% CI: 0.47 to 0.99; p = 0.044) mortality. Rates of myocardial infarction (2.01% vs. 2.05%; p = 0.88), stent thrombosis (0.29% vs. 0.38%; p = 0.32), and stroke (0.47% vs. 0.36%; p = 0.30) were similar. CONCLUSIONS Ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without a concomitant increase in ischemic events.
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Affiliation(s)
- Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland.
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bruno R da Costa
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Eùgene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands; Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Sergio Leonardi
- University of Pavia and Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Davide Cao
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - George D Dangas
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shamir R Mehta
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Patrick W Serruys
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Gabriel P Steg
- Université de Paris and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Samin K Sharma
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian Hamm
- German Center for Cardiovascular Research, partner site RheinMain, Frankfurt am Main, Germany; Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Richard Shlofmitz
- Department of Cardiology, St. Francis Hospital, Roslyn, New York, USA
| | - Christoph Liebetrau
- German Center for Cardiovascular Research, partner site RheinMain, Frankfurt am Main, Germany; Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | | | | | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University Medical School, Vienna, Austria
| | - Maurizio Ferrario
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - David J Cohen
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Aleksander Zurakowski
- Department of Interventional Cardiology Chrzanów, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Keith G Oldroyd
- The West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Han Yaling
- General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Dariuz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian Kirkham
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Javier Escaned
- Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Madrid, Spain
| | - Dik Heg
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Jüni
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Li J, He K, Ge J, Li C, Jing Z. Short-term vs long-term dual antiplatelet therapy after drug-eluting stent implantation in patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis. Int J Clin Pract 2021; 75:e13938. [PMID: 33341109 DOI: 10.1111/ijcp.13938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 12/14/2020] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is under controversial. The aim of the present systematic review and meta-analysis was to evaluate the safety and efficacy of short-term (≤6 months) DAPT vs long-term (≥12 months) DAPT after PCI with a drug-eluting stent (DES). METHODS We systematically searched the Cochrane Library, PubMed and Embase databases to identify randomised controlled trials (RCTs) that compared short-term (≤6 months) and long-term (≥12 months) DAPT. The endpoints included major bleeding, any bleeding, death from any cause, cardiac death, myocardial infarction, stroke, stent thrombosis and target vessel revascularisation. The primary outcome was major bleeding. A fixed-effects model was used to calculate the risk ratio (RR) and 95% confidence interval (CI) of each endpoint. RESULTS Eighteen trials involving 57,940 patients were included. Compared with long-term DAPT, short-term DAPT resulted in lower rates of major bleeding [RR 0.75, 95% CI 0.65-0.87, P = .0002] and any bleeding [RR 0.61, 95% CI 0.54-0.69, P < .00001]. No significant difference was observed in the outcomes of death from any cause, cardiac death, myocardial infarction, stroke, stent thrombosis, or target vessel revascularisation. The subgroup analysis according to different DAPT durations, mono antiplatelet therapies (MAPTs), countries and P2Y12 inhibitors produced similar outcomes as comprehensive outcomes. CONCLUSIONS Compared with long-term DAPT, short-term DAPT did not increase the risk of ischemic complications but did reduce the risks of major bleeding and any bleeding by over 25%. This study showed that short-term DAPT could be considered for most patients after DES implantation.
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Affiliation(s)
- Jingxin Li
- Department of Chinese pharmacy, Hebei Maternity Hospital, Shijiazhuang, Hebei Province, China
| | - Ke He
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, China
| | - Jun Ge
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, China
| | - Caixia Li
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, China
| | - Zeng Jing
- Department of Pharmacy, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei Province, China
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8
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Valgimigli M, Gragnano F, Branca M, Franzone A, Baber U, Jang Y, Kimura T, Hahn JY, Zhao Q, Windecker S, Gibson CM, Kim BK, Watanabe H, Song YB, Zhu Y, Vranckx P, Mehta S, Hong SJ, Ando K, Gwon HC, Serruys PW, Dangas GD, McFadden EP, Angiolillo DJ, Heg D, Jüni P, Mehran R. P2Y12 inhibitor monotherapy or dual antiplatelet therapy after coronary revascularisation: individual patient level meta-analysis of randomised controlled trials. BMJ 2021; 373:n1332. [PMID: 34135011 PMCID: PMC8207247 DOI: 10.1136/bmj.n1332] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the risks and benefits of P2Y12 inhibitor monotherapy compared with dual antiplatelet therapy (DAPT) and whether these associations are modified by patients' characteristics. DESIGN Individual patient level meta-analysis of randomised controlled trials. DATA SOURCES Searches were conducted in Ovid Medline, Embase, and three websites (www.tctmd.com, www.escardio.org, www.acc.org/cardiosourceplus) from inception to 16 July 2020. The primary authors provided individual participant data. ELIGIBILITY CRITERIA Randomised controlled trials comparing effects of oral P2Y12 monotherapy and DAPT on centrally adjudicated endpoints after coronary revascularisation in patients without an indication for oral anticoagulation. MAIN OUTCOME MEASURES The primary outcome was a composite of all cause death, myocardial infarction, and stroke, tested for non-inferiority against a margin of 1.15 for the hazard ratio. The key safety endpoint was Bleeding Academic Research Consortium (BARC) type 3 or type 5 bleeding. RESULTS The meta-analysis included data from six trials, including 24 096 patients. The primary outcome occurred in 283 (2.95%) patients with P2Y12 inhibitor monotherapy and 315 (3.27%) with DAPT in the per protocol population (hazard ratio 0.93, 95% confidence interval 0.79 to 1.09; P=0.005 for non-inferiority; P=0.38 for superiority; τ2=0.00) and in 303 (2.94%) with P2Y12 inhibitor monotherapy and 338 (3.36%) with DAPT in the intention to treat population (0.90, 0.77 to 1.05; P=0.18 for superiority; τ2=0.00). The treatment effect was consistent across all subgroups, except for sex (P for interaction=0.02), suggesting that P2Y12 inhibitor monotherapy lowers the risk of the primary ischaemic endpoint in women (hazard ratio 0.64, 0.46 to 0.89) but not in men (1.00, 0.83 to 1.19). The risk of bleeding was lower with P2Y12 inhibitor monotherapy than with DAPT (97 (0.89%) v 197 (1.83%); hazard ratio 0.49, 0.39 to 0.63; P<0.001; τ2=0.03), which was consistent across subgroups, except for type of P2Y12 inhibitor (P for interaction=0.02), suggesting greater benefit when a newer P2Y12 inhibitor rather than clopidogrel was part of the DAPT regimen. CONCLUSIONS P2Y12 inhibitor monotherapy was associated with a similar risk of death, myocardial infarction, or stroke, with evidence that this association may be modified by sex, and a lower bleeding risk compared with DAPT. REGISTRATION PROSPERO CRD42020176853.
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Affiliation(s)
- Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
- Contributed equally
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
- Contributed equally
| | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yangsoo Jang
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Charles M Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Belgium
| | - Shamir Mehta
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Kenji Ando
- Kokura Memorial Hospital, Department of Cardiology, Kitakyushu, Japan
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway, Galway, Ireland
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Eùgene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, Netherlands
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Dik Heg
- Clinical Trials Unit, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Contributed equally
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Contributed equally
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9
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Kuno T, Ueyama H, Takagi H, Bangalore S. Choosing between aspirin or P2Y12 monotherapy after short course of DAPT. Am Heart J 2020; 230:100. [PMID: 33248474 DOI: 10.1016/j.ahj.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY.
| | - Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University Grossman School of Medicine, New York, NY
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10
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Choudhary R, Kumari V. Aspirin versus P2Y12 inhibitor-based monotherapy after percutaneous coronary intervention. Am Heart J 2020; 230:99. [PMID: 33248476 DOI: 10.1016/j.ahj.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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11
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Kuno T, Takagi H, Ando T, Kodaira M, Numasawa Y, Fox J, Bangalore S. Safety and efficacy of mechanical circulatory support with Impella or intra‐aortic balloon pump for high‐risk percutaneous coronary intervention and/or cardiogenic shock: Insights from a network meta‐analysis of randomized trials. Catheter Cardiovasc Interv 2020; 97:E636-E645. [DOI: 10.1002/ccd.29236] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/28/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Toshiki Kuno
- Department of Medicine Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel New York New York
| | - Hisato Takagi
- Department of Cardiovascular Surgery Shizuoka Medical Center Shizuoka Japan
| | - Tomo Ando
- Division of Cardiology Center for Interventional Vascular Therapy, NewYork‐Presbyterian Hospital/Columbia University Medical Center New York New York
| | - Masaki Kodaira
- Department of Cardiology Japanese Red Cross Ashikaga Hospital Ashikaga Japan
| | - Yohei Numasawa
- Department of Cardiology Japanese Red Cross Ashikaga Hospital Ashikaga Japan
| | - John Fox
- Department of Cardiology Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel New York New York
| | - Sripal Bangalore
- Division of Cardiology University School of Medicine New York New York
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