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Fujisaki T, Kuno T, Iwagami M, Miyamoto Y, Takagi H, Deharo P, Cuisset T, Briasoulis A, Panaich S, Latib A, Kohsaka S. Net clinical benefit of dual antiplatelet therapy in elderly patients with acute coronary syndrome: A systematic review and meta-analysis. Catheter Cardiovasc Interv 2023; 102:788-802. [PMID: 37675959 DOI: 10.1002/ccd.30811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/15/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Contemporary dual antiplatelet therapy (DAPT) strategies, such as short-term DAPT or de-escalation of DAPT, have emerged as attractive strategies to treat patients with acute coronary syndrome (ACS). However, it remains uncertain whether they are suitable for elderly patients. METHODS PubMed, Embase, and Cochrane CENTRAL databases were searched in September 2022. Randomized controlled trials (RCTs) investigating DAPT strategies, including standard (12 months), short-term, uniform de-escalation, and guided-selection strategies for elderly patients with ACS (age ≥ 65 years) were identified, and a network meta-analysis was conducted. The primary endpoint was the net clinical benefit outcome, a composite of major adverse cardiovascular events (MACEs: cardiovascular death, myocardial infarction, or stroke) and clinically relevant bleeding (equivalent to bleeding of at least type 2 according to the Bleeding Academic Research Consortium). The secondary outcomes were MACE and major bleeding. RESULTS Sixteen RCTs with a combined total of 47,911 patients were included. The uniform de-escalation strategy was associated with an improved net clinical benefit compared with DAPT using potent P2Y12 inhibitors. The short-term DAPT strategy was associated with reduced risks of the primary outcome and major bleeding compared with DAPT using potent P2Y12 inhibitors, however, it was ranked as the least effective strategy for MACE compared with other DAPT strategies. CONCLUSIONS Uniform de-escalation and short-term DAPT strategies may be advantageous for elderly patients, but need to be tailored based on individual bleeding and ischemic risks. Further RCTs of contemporary DAPT strategies specifically designed for elderly patients are warranted to confirm the findings of the present study.
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Affiliation(s)
- Tomohiro Fujisaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
- Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Yoshihisa Miyamoto
- Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France
- Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France
- Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | | | - Sidakpal Panaich
- Division of Cardiovascular Medicine, University of Iowa, Iowa, Iowa, USA
| | - Azeem Latib
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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