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Casula M, Casu G, Talanas G, Spano A, Tantry U, Bilotta F, Micheluzzi V, Merella P, Porcheddu T, Gorog DA, Bonaca M, Jeong YH, Farkouh ME, Kubica J, Isgender M, Gurbel PA, Navarese EP. Efficacy and Safety of P2Y 12 monotherapy vs standard DAPT in patients undergoing percutaneous coronary intervention: meta-analysis of randomized trials. Curr Probl Cardiol 2024; 49:102635. [PMID: 38750991 DOI: 10.1016/j.cpcardiol.2024.102635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 05/08/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND Debates persist regarding the optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in coronary artery disease (CAD). Recent trials have introduced a novel approach involving P2Y12 inhibitor monotherapy with ticagrelor or clopidogrel, after a short DAPT. However, the effectiveness and safety of this strategy remains to be established. We aimed to perform a meta-analysis comparing monotherapy with P2Y12 inhibitors versus standard DAPT in patients undergoing PCI at 12 months. METHODS Multiple databases were searched. Six RCTs with a total of 24877 patients were included. The primary endpoint was all-cause mortality at 12 months of follow-up. The secondary endpoints were cardiovascular mortality, myocardial infarction, probable or definite stent thrombosis, stroke events, and major bleeding. The study is registered with PROSPERO (CRD42024499529). RESULTS Monotherapy with P2Y12 inhibitor ticagrelor significantly reduced both allcause mortality (HR 0.71, 95 CI [0.55-0.91], P = 0.007) and cardiovascular mortality (HR 0.66, 95% CI [0.49-0.89], P = 0.006) compared to standard DAPT. In contrast, clopidogrel monotherapy did not demonstrate a similar reduction. The decrease in mortality associated with ticagrelor was primarily due to a lower risk of major bleeding (HR 0.56, 95% CI [0.43-0.72], P < 0.001), while the risk of myocardial infarction (MI) remained unchanged (HR 0.90, 95% CI [0.73-1.11], P = 0.32). The risk of stroke was found to be similar across treatments. CONCLUSIONS In comparison to standard DAPT, P2Y12 inhibitor monotherapy with ticagrelor may lead to a reduced mortality. The clinical benefits are driven by a reduction of bleeding risk without ischemic risk trade-off.
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Affiliation(s)
- Marta Casula
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Gavino Casu
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Giuseppe Talanas
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Andrea Spano
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Udaya Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Ferruccio Bilotta
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Valentina Micheluzzi
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Pierluigi Merella
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Tomaso Porcheddu
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy
| | - Diana A Gorog
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
| | - Marc Bonaca
- CPC Clinical Research, University of Colorado School of Medicine, USA
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Heart and Brain Hospital, Chung-Ang University, Gwangmyeong Hospital, Gwangmyeong, South Korea; Department of Internal Medicine, Chung-Ang University School of Medicine, Seoul, South Korea
| | | | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Mehriban Isgender
- Republican Clinical Hospital, Department of Cardiology, Azerbaijan Medical University, Department of Family Medicine, Baku, Azerbaijan
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Eliano Pio Navarese
- Clinical Experimental Cardiology, Clinical and Interventional Cardiology, University of Sassari, Sassari, Sardinia Island, Italy; Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy; SIRIO MEDICINE Research Network, Sassari, Italy.
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Khalid AR, Ahmad F, Naeem MAB, Ahmed S, Umar M, Mehmood H, Kashif M, Ali S. Safety of Clopidogrel vs. Ticagrelor in Dual Antiplatelet Therapy Regimens for High-Bleeding Risk Acute Coronary Syndrome Patients: A Comprehensive Meta-analysis of Adverse Outcomes. High Blood Press Cardiovasc Prev 2024; 31:141-155. [PMID: 38557855 DOI: 10.1007/s40292-024-00635-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/09/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Patients of acute coronary syndrome (ACS) at a high-bleeding risk (HBR) often require dual antiplatelet therapy (DAPT) to reduce the risk of recurrent cardiovascular events. Clopidogrel and ticagrelor are the most commonly used antiplatelet agents in DAPT regimens. However, the safety profiles of these drugs in ACS patients at HBR remain a subject of ongoing debate. AIM To investigate any difference between the safety of clopidogrel and ticagrelor used as a part of DAPT regimen in ACS patients at HBR. METHODS A systematic search on PubMed, Cochrane Library, and Google Scholar was conducted to identify experimental and observational studies published up to the knowledge cutoff date in September 2023. Studies comparing the safety of clopidogrel and ticagrelor in ACS patients at HBR were included for analysis. The primary outcomes assessed were major bleeding events, stroke, and myocardial infarction (MI), while secondary outcomes included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), and net adverse clinical and cerebral events (NACCE). RESULTS We included a total of 8 observational studies in our meta-analysis. The pooled analysis revealed a statistically significant increase in the risk of MI (pooled RR = 1.43; 95% CI 1.12-1.83; P = 0.005) in the patients using clopidogrel. There were no statistically significant differences in major bleeding events (pooled RR = 0.94; 95% CI 0.82-1.09; P = 0.44), stroke (pooled RR = 1.36; 95% CI 0.86-2.14; P = 0.18), all-cause mortality (pooled RR = 1.17; 95% CI 0.97-1.41; P = 0.10), MACCE (pooled RR = 1.07; 95% CI 0.76-1.50; P = 0.69) and NACCE (pooled RR = 0.95; 95% CI 0.66-1.37; P = 0.78) between the two groups. Subgroup analyses based on region were performed. CONCLUSION Both drugs are generally safe for treating ACS patients with HBR at baseline, although a higher risk of MI was observed with the use of clopidogrel. Nevertheless, drug choice should factor in regional variations, patient-specific characteristics, cost, accessibility, and potential drug interactions.
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Affiliation(s)
| | - Farooq Ahmad
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | | | - Smak Ahmed
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | - Muhammad Umar
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | | | | | - Shazib Ali
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
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Tjerkaski J, Jernberg T, Szummer K. Balancing the risks of bleeding and ischaemia in myocardial infarction patients at high bleeding risk. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:770-771. [PMID: 37740444 PMCID: PMC10719447 DOI: 10.1093/ehjcvp/pvad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/24/2023]
Affiliation(s)
- J Tjerkaski
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm 182 88, Sweden
| | - T Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institute, Stockholm 182 88, Sweden
| | - K Szummer
- Section of Cardiology, Department of Medicine, Karolinska Institutet, Huddinge, Stockholm 171 77, Sweden
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De Luca L, Gragnano F, Calabrò P, Huber K. Balancing Benefits and Risks of Oral Antiplatelet Strategies in patients With Coronary Artery Diseases: An Evolving Issue. Curr Probl Cardiol 2023; 48:102025. [PMID: 37553063 DOI: 10.1016/j.cpcardiol.2023.102025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023]
Abstract
Identifying the most appropriate antiplatelet therapy for each patient to prevent ischemic events while minimizing the risk of bleeding is an integral part of the short- and long-term management of patients with coronary artery disease (CAD). This review aims to summarize the available evidence on the contemporary use of P2Y12 inhibitors in CAD patients, focusing on strategies aimed at providing adequate ischemic protection while preventing bleeding risk through dual antiplatelet therapy (DAPT) modulation. Randomized trials and observational studies have been reviewed to determine the most appropriate antiplatelet treatment for CAD patients with different risk profiles. Both ischemic and bleeding events have a significant prognostic impact and should be carefully considered in clinical decision-making. Current guidelines recommend the use of third-generation PY2Y12 inhibitors (prasugrel or ticagrelor) over clopidogrel, as a part of DAPT, in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention. Newer P2Y12 inhibitors have a more rapid onset of action and less interindividual variability in platelet inhibition than clopidogrel but are associated with an increased risk of bleeding that may limit their benefit. Importantly, the anti-ischemic benefit of ticagrelor and prasugrel is mainly observed in the first weeks after ACS, whereas clopidogrel seems to provide the best balance between ischemic protection and bleeding as long-term maintenance therapy. These concepts support DAPT modulation after the acute phase, by de-escalating from full-dose to low-dose newer P2Y12 inhibitors, by switching to clopidogrel, or by early withdrawing aspirin to maximize both the efficacy and safety of antiplatelet therapy in patients with CAD.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, A.O. San Camillo-Forlanini, Roma, Italy.
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, AORN "Sant'anna e San Sebastiano", Caserta, Italy
| | - Kurt Huber
- Department of Cardiology and Intensive Care Medicine, Clinic Ottakring, and Sigmund Freud University, Medical Faculty, Vienna, Austria
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Dimitriadis K, Pyrpyris N, Aznaouridis K, Tsioufis K. P2Y12 inhibition in high bleeding risk patients: making the right decision in a complex setting. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:669. [PMID: 37553152 DOI: 10.1093/ehjcvp/pvad056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/07/2023] [Indexed: 08/10/2023]
Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Konstantinos Aznaouridis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, 115 27, Athens, Greece
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