Gender-related differences in antiplatelet treatment patterns and outcome: Insights from the GReekAntiPlatElet Registry

Risk of postoperative bleeding after dental extraction in patients on antiplatelet therapy: systematic review and meta-analysis

OBJECTIVE

To determine the risk of bleeding after minor extraction in patients on different antiplatelet therapy (APT) regimens.

STUDY DESIGN

A search was conducted using PubMed and Google Scholar. Thirty-five papers were included in the systematic review, of which 23 papers provided the requisite information for meta-analysis. Subgroups were created based on the controls, as follows: (1) no control, (2) healthy control, and (3) interrupted APT control. In a meta-analysis, the studies were further subdivided into immediate and delayed bleeding.

RESULTS

No immediate or delayed bleeding risk was found in patients treated with aspirin vs healthy controls (relative risk [RR] = 1.26; P = .5 and RR = 2.17; P = .09, respectively). A higher immediate bleeding was recorded for patients on single nonaspirin APT vs those in the healthy population (RR = 3.72; P = .0009). A high risk of bleeding was recorded in patients receiving dual APT compared with healthy controls for immediate (RR = 10.3; P < .0001) and delayed (RR = 7.72; P = .001) bleeding. Dual APT continuation showed a higher risk of immediate bleeding (RR = 2.13) than interrupted APT, but the difference was insignificant (P = .07).

CONCLUSIONS

Dental extraction can be performed safely in patients on aspirin monotherapy. In contrast, patients receiving dual APT should be considered at risk for immediate and continued bleeding.

Sex differences in antiplatelet therapy: state-of-the art

Antiplatelet therapy is a cornerstone of secondary prevention of cardiovascular diseases (CVDs). However, current guidelines are based on data derived primarily from men, as women are generally underrepresented in trials. Consequently, there are insufficient and inconsistent data on the effect of antiplatelet drugs in women. Sex differences were reported in platelet reactivity, patient management, and clinical outcomes after treatment with aspirin, P2Y₁₂ inhibitor, or dual antiplatelet therapy. To evaluate whether sex-specific antiplatelet therapy is needed, in this review we discuss (i) how sex affects platelet biology and response to antiplatelet agents, (ii) how sex and gender differences translate into clinical challenges and (iii) how the cardiological care in women might be improved. Finally, we highlight the challenges faced in clinical practice regarding the different needs and characteristics of female and male patients with CVD and address issues requiring further investigation.

Sex-Based Differences in Bleeding Risk After Percutaneous Coronary Intervention and Implications for the Academic Research Consortium High Bleeding Risk Criteria

Background

Female sex was not included among the high bleeding risk (HBR) criteria by the Academic Research Consortium (ARC) as it remains unclear whether it constitutes an HBR condition after percutaneous coronary intervention. We investigated whether female sex associates with HBR and assessed the performance of ARC HBR criteria separately in women and men.

Methods and Results

Among all consecutive patients undergoing percutaneous coronary intervention between 2009 and 2018, bleeding occurrences up to 1 year were prospectively collected and centrally adjudicated. All but one of the originally defined ARC HBR criteria were assessed, and the ARC HBR score generated accordingly. Among 16 821 patients, 25.6% were women. Compared with men, women were older and had lower creatinine clearance and hemoglobin values. After adjustment, female sex was independently associated with access‐site (adjusted hazard ratio, 2.14; 95% CI, 1.22–3.74; P=0.008) but not with overall or non–access‐site 1‐year Bleeding Academic Research Consortium 3 or 5 bleeding. This association remained consistent when the femoral but not the radial approach was chosen. The ARC HBR score discrimination, using the original criteria, was lower among women than men (c‐index 0.644 versus 0.688; P=0.048), whereas a revised ARC HBR score, in which age, creatinine clearance, and hemoglobin were modeled as continuous rather than dichotomized variables, performed similarly in both sexes.

Conclusions

Female sex is an independent predictor for access‐site bleeding but not for overall bleeding events at 1 year after percutaneous coronary intervention. The ARC HBR framework shows an overall good performance in both sexes, yet is lower in women than men, attributable to dichotomization of age, creatinine clearance, and hemoglobin values, which are differently distributed between sexes.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02241291.

Efficacy and Safety of High Potent P2Y12 Inhibitors Prasugrel and Ticagrelor in Patients With Coronary Heart Disease Treated With Dual Antiplatelet Therapy: A Sex-Specific Systematic Review and Meta-Analysis

Background

Sex differences in efficacy and safety of dual antiplatelet therapy remain uncertain because of the underrepresentation of women in cardiovascular trials. The aim of this study was to perform a sex‐specific analysis of the pooled efficacy and safety data of clinical trials comparing a high potent P2Y₁₂ inhibitor+aspirin with clopidogrel+aspirin in patients with acute coronary syndrome.

Methods and Results

A systematic literature search was performed. Randomized clinical trials that compared patients following percutaneous coronary intervention/acute coronary syndrome who were taking high potent P2Y₁₂ inhibitors+aspirin versus clopidogrel+aspirin were selected. Random effects estimates were calculated and relative risks with 95% CIs on efficacy and safety end points were determined per sex. We included 6 randomized clinical trials comparing prasugrel/ticagrelor versus clopidogrel in 43 990 patients (13 030 women), with a median follow‐up time of 1.06 years. Women and men had similar relative risk (RR) reduction for major cardiovascular events (women: RR, 0.89 [95% CI, 0.80–1.00; men: RR, 0.84 [95% CI, 0.79–0.91) (P for interaction=0.39). Regarding safety, women and men had similar risk of major bleeding by high‐potency dual antiplatelet therapy (RR, 1.18 [95% CI, 0.98–1.41] versus RR, 1.03 [95% CI, 0.93–1.14]) (P for interaction=0.20).

Conclusions

The small and statistically insignificant difference in efficacy and safety estimates of high‐potency dual antiplatelet therapy between women and men following percutaneous coronary intervention/acute coronary syndrome do not justify differential dual antiplatelet therapy treatment for both sexes.

Ticagrelor for Asian patients with acute coronary syndrome in real-world practice: A systematic review and meta-analysis of observational studies

Objective

We aimed to assess the efficacy and safety of ticagrelor compared to clopidogrel in Asian patients with acute coronary syndrome (ACS) in real-world practice.

Methods

PubMed, Web of Science and Scopus databases were searched systematically to obtain relevant Asian observational studies.

Results

The meta-analysis included six studies with 27959 participants. Compared with clopidogrel, ticagrelor was significantly beneficial in prevention of major adverse cardiac events (MACCEs) (OR=0.62; 95% CI: 0.46-0.83, I²=69%, p=0.001) mainly driven by reducing stroke (OR=0.62; 95% CI: 0.49-0.78, I²=0%, p<0.001). No differences were found between ticagrelor and clopidogrel in the risk of cardiovascular mortality (OR=0.66; 95% CI: 0.41-1.06, I²=0%, p=0.09), target vessel revascularization (OR=0.53; 95% CI: 0.21-1.35, I²=82%, p=0.18), major bleeding (OR=1.11; 95% CI: 0.62-2.00, I²=75%, p=0.73), and net adverse clinical and cerebral events (OR=0.76; 95% CI: 0.55-1.04, I²=78%, p=0.09). However, ticagrelor significantly increased the incidence of major/minor (OR=1.73; 95% CI: 1.36-2.21, I²=0%, p<0.001) and minor bleeding (OR=1.73; 95% CI: 1.29-2.32, I²=0%, p<0.001). Sensitivity analyses did not find consistent effect of ticagrelor on prevention of all-cause death and myocardial infarction.

Conclusion

This meta-analysis suggested that ticagrelor might reduce the risk of MACCEs mainly by reducing stroke in Asian patients with ACS without increasing the rates of major bleeding. Ticagrelor did not show a significant effect on other parts of MACCEs. Considerable increase in the risk of major/minor and minor bleeding was observed in ticagrelor compared with clopidogrel users. Further high-quality studies are required to support these findings.

Gender-Related Differences in Antiplatelet Therapy and Impact on 1-Year Clinical Outcome in Patients Presenting With ACS: The START ANTIPLATELET Registry

We investigated whether gender influences antiplatelet treatment in patients with acute coronary syndrome (ACS). The primary end point was major adverse cardiac and cerebrovascular events (MACCEs), a composite of death, myocardial infarction (MI), stroke, or target vessel revascularization. The coprimary end point was net adverse cardiac and cerebrovascular events (NACEs), based on MACCE plus major bleeding. From January 2014 to December 2016, 840 consecutive patients with ACS who completed 1-year follow-up were enrolled, 625 (74%) males and 215 (26%) females. Percutaneous coronary interventions (PCI) and drug-eluting stents (DES) were more often used in males (PCI: 532 [87%] vs 168 [80%], P = .02 and DES 474 [76%] vs 143 [66%], P = .01). Males were more often treated with dual antiplatelet therapy (DAPT; 94% vs 88%, P = .01). In DAPT, ticagrelor was the most prevalent strategy, regardless of gender (47% vs 49%, P = .68); clopidogrel was preferred in women (42% vs 33%, P = .04); and prasugrel was preferred in men (11% vs 17%, P = .04). At multivariate analysis, MACCE and NACE were similar between genders. Therefore, although P2Y12 inhibitor choice in DAPT might be influenced by gender, a DAPT choice, tailored by balancing the ischemic/bleeding risk, has a similar clinical outcome irrespective of gender.