1
|
Agewall S. The search for the holy grail: the balance between the risk of thrombosis and bleeding in patients. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:367-369. [PMID: 39141000 DOI: 10.1093/ehjcvp/pvae052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief
- Institute of Clinical Sciences, Karolinska Institute of Danderyd, Stockholm, Sweden
| |
Collapse
|
2
|
Li Y, Li J, Wang B, Jing Q, Zeng Y, Hou A, Wang Z, Liu A, Zhang J, Zhang Y, Zhang P, Jiang D, Liu B, Fan J, Zhang J, Li L, Su G, Yang M, Jiang W, Qu P, Zeng H, Li L, Qiu M, Ru L, Chen S, Zhou Y, Qiao S, Stone GW, Angiolillo DJ, Han Y. Extended Clopidogrel Monotherapy vs DAPT in Patients With Acute Coronary Syndromes at High Ischemic and Bleeding Risk: The OPT-BIRISK Randomized Clinical Trial. JAMA Cardiol 2024; 9:523-531. [PMID: 38630489 PMCID: PMC11024736 DOI: 10.1001/jamacardio.2024.0534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/02/2024] [Indexed: 04/20/2024]
Abstract
Importance Purinergic receptor P2Y12 (P2Y12) inhibitor monotherapy after a certain period of dual antiplatelet therapy (DAPT) may be an attractive option of maintenance antiplatelet treatment for patients undergoing percutaneous coronary intervention (PCI) who are at both high bleeding and ischemic risk (birisk). Objective To determine if extended P2Y12 inhibitor monotherapy with clopidogrel is superior to ongoing DAPT with aspirin and clopidogrel after 9 to 12 months of DAPT after PCI in birisk patients with acute coronary syndromes (ACS). Design, Setting, and Participants This was a multicenter, double-blind, placebo-controlled, randomized clinical trial including birisk patients with ACS who had completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months at 101 China centers between February 2018 and December 2020. Study data were analyzed from April 2023 to May 2023. Interventions Patients were randomized either to clopidogrel plus placebo or clopidogrel plus aspirin for an additional 9 months. Main Outcomes and Measures The primary end point was Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 bleeding 9 months after randomization. The key secondary end point was major adverse cardiac and cerebral events (MACCE; the composite of all-cause death, myocardial infarction, stroke or clinically driven revascularization). The primary end point was tested for superiority, and the MACCE end point was tested for sequential noninferiority and superiority. Results A total of 7758 patients (mean [SD] age, 64.8 [9.0] years; 4575 male [59.0%]) were included in this study. The primary end point of BARC types 2, 3, or 5 bleeding occurred in 95 of 3873 patients (2.5%) assigned to clopidogrel plus placebo and 127 of 3885 patients (3.3%) assigned to clopidogrel plus aspirin (hazard ratio [HR], 0.75; 95% CI, 0.57-0.97; difference, -0.8%; 95% CI, -1.6% to -0.1%; P = .03). The incidence of MACCE was 2.6% (101 of 3873 patients) in the clopidogrel plus placebo group and 3.5% (136 of 3885 patients) in the clopidogrel plus aspirin group (HR, 0.74; 95% CI, 0.57-0.96; difference, -0.9%; 95% CI, -1.7% to -0.1%; P < .001 for noninferiority; P = .02 for superiority). Conclusions and Relevance Among birisk patients with ACS who completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months before randomization, an extended 9-month clopidogrel monotherapy regimen was superior to continuing DAPT with clopidogrel in reducing clinically relevant bleeding without increasing ischemic events. Trial Registration ClinicalTrials.gov Identifier: NCT03431142.
Collapse
Affiliation(s)
- Yi Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Bin Wang
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Quanmin Jing
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Yujie Zeng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Aijie Hou
- The People’s Hospital of Liaoning Province, Shenyang, China
| | | | - Aijun Liu
- Benxi Central Hospital, Benxi, China
| | | | | | - Ping Zhang
- Beijing Tsinghua Changgung Hospital, Beijing, China
| | | | - Bin Liu
- The Second Hospital of Jilin University, Changchun, China
| | | | - Jun Zhang
- Cangzhou Central Hospital, Cangzhou, China
| | - Li Li
- Guangzhou Red Cross Hospital, Guangzhou, China
| | - Guohai Su
- Central Hospital Affiliated to Shandong First Medical University, Ji’nan, China
| | - Ming Yang
- Yingkou Central Hospital, Yingkou, China
| | - Weihong Jiang
- The Third Xiangya Hospital of Central South University, Changsha, China
| | - Peng Qu
- The Second Hospital of Dalian Medical University, Dalian, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Lu Li
- The Second Affiliated Hospital of Shenyang Medical College, Shenyang, China
| | - Miaohan Qiu
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Leisheng Ru
- Bethune International Peace Hospital, Shijiazhuang, China
| | | | - Yujie Zhou
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shubin Qiao
- Fuwai Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Yaling Han
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| |
Collapse
|
3
|
Apostolos A, Chlorogiannis DD, Chrysostomidis G, Bozika M, Timpilis F, Kramvis A, Karamasis GV, Leventopoulos G, Davlouros P, Tsigkas G. Efficacy and Safety of Thirty-Day Dual-Antiplatelet Therapy Following Complex Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2024; 11:43. [PMID: 38392257 PMCID: PMC10889500 DOI: 10.3390/jcdd11020043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
The optimal duration of DAPT after complex PCI remains under investigation. The purpose of this systematic review and meta-analysis was to explore the safety and efficacy of a one-month therapy period versus a longer duration of DAPT after complex PCI. We systematically screened three major databases, searching for randomized controlled trials or sub-analyses of them, which compared shortened DAPT (S-DAPT), namely, one month, and longer DAPT (L-DAPT), namely, more than three months. The primary endpoint was any Net Adverse Clinical Event (NACE), and the secondary was any MACE (Major Adverse Cardiac Event), its components (mortality, myocardial infarction, stroke, and stent thrombosis), and major bleeding events. Three studies were included in the analysis, with a total of 6275 patients. Shortening DAPT to 30 days after complex PCI did not increase the risk of NACEs (OR: 0.77, 95% CI: 0.52-1.14), MACEs, mortality, myocardial infractions, stroke, or stent thrombosis. Pooled major bleeding incidence was reduced, but this finding was not statistically significant. This systematic review and meta-analysis showed that one-month DAPT did not differ compared to a longer duration of DAPT after complex PCI in terms of safety and efficacy endpoints. Further studies are still required to confirm these findings.
Collapse
Affiliation(s)
- Anastasios Apostolos
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | | | | | - Maria Bozika
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Filippos Timpilis
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Angelos Kramvis
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Grigoris V Karamasis
- Second Cardiology Department, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Chaidari, 124 62 Athens, Greece
| | | | - Periklis Davlouros
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| |
Collapse
|
4
|
Agewall S. Cardiovascular prevention and risk factors. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:1-2. [PMID: 38000082 DOI: 10.1093/ehjcvp/pvad087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023]
Affiliation(s)
- Stefan Agewall
- Institute of Clinical Sciences, Karolinska Institute of Danderyd, Stockholm, Sweden
| |
Collapse
|
5
|
Agewall S. Antiplatelet treatment after PCI. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:593-594. [PMID: 37846590 DOI: 10.1093/ehjcvp/pvad071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 10/12/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Stefan Agewall
- Institute of Clinical Sciences, Karolinska Institute of Danderyd, 171 77 Stockholm, Sweden
| |
Collapse
|
6
|
Yu Y, Pan D, Bai R, Luo J, Tan Y, Duan W, Shi D. P2y 12 inhibitor monotherapy after 1-3 months dual antiplatelet therapy in patients with coronary artery disease and chronic kidney disease undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197161. [PMID: 37485257 PMCID: PMC10357506 DOI: 10.3389/fcvm.2023.1197161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction In patients with coronary artery disease (CAD) and chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI), whether short-term dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitors confers benefits compared with standard DAPT remains unclear. This study aimed to assess the efficacy and safety of 1-3 months of DAPT followed by P2Y12 monotherapy in patients with CAD and CKD undergoing PCI. Methods PubMed, Embase, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) comparing the P2Y12 inhibitor monotherapy after a 1-3 months DAPT vs. DAPT in patients with CAD and CKD after PCI. The primary outcome was the incidence of major adverse cardiovascular events (MACEs), defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, target-vessel revascularization, and stroke. The safety outcome was the major bleeding events, defined as a composite of TIMI major bleeding or Bleeding Academic Research and Consortium (BARC) type 2, 3, or 5 bleeding. The pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated with a fixed- or random-effects model depending on the heterogeneity among studies. Results Four RCTs including 20,468 patients (2,833 patients with CKD and 17,635 without CKD) comparing P2Y12 inhibitor monotherapy with DAPT were included in our meta-analysis. Patients with CAD and CKD had higher risk of ischemic and bleeding events. P2Y12 inhibitor monotherapy after 1-3 months of DAPT significantly reduced the risk of major bleeding compared to DAPT in CKD patients (RR: 0.69, 95% CI: 0.51-0.95, P = 0.02) and non-CKD patients (RR: 0.66, 95% CI: 0.49-0.89, P = 0.01). No significant difference regarding MACEs between P2Y12 inhibitor monotherapy and DAPT was found in CKD patients (RR: 0.88, 95% CI: 0.59-1.31, P = 0.53) and non-CKD (RR: 0.91, 95% CI: 0.79-1.04, P = 0.17). Conclusion P2Y12 inhibitor monotherapy after 1-3 months of DAPT was an effective strategy for lowering major bleeding complications without increasing the risk of cardiovascular events in patients with CAD and CKD undergoing PCI as compared with DAPT. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, CRD42022355228.
Collapse
Affiliation(s)
- Yanqiao Yu
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Deng Pan
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruina Bai
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinwen Luo
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yu Tan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wenhui Duan
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dazhuo Shi
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| |
Collapse
|
7
|
Li H, Liu H, Yan LJ, Ding ZN, Zhang X, Pan GQ, Han CL, Tian BW, Tan SY, Dong ZR, Wang DX, Yan YC, Li T. Performance of GALAD score and serum biomarkers for detecting NAFLD-related HCC: a systematic review and network meta-analysis. Expert Rev Gastroenterol Hepatol 2023; 17:1159-1167. [PMID: 37929312 DOI: 10.1080/17474124.2023.2279175] [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] [Received: 06/14/2023] [Accepted: 10/31/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION The incidence of nonalcoholic fatty liver disease (NAFLD)-related hepatocellular carcinoma (HCC) is increasing globally. We aimed to assess the performance of alpha-fetoprotein (AFP), AFP-L3, des-gamma-carboxy prothrombin (DCP), and GALAD score in detecting NAFLD-related HCC. METHODS We searched the relevant literature in PubMed, Embase and Cochrane. Conventional and network meta-analyses were performed for sensitivity, specificity, Youden index (YI), and the area under the summary receiver operator characteristic curve (AUC). RESULTS Fifteen studies involving 2031 NAFLD participants were included in this meta-analysis. When detecting early-stage NAFLD-related HCC, GALAD score and DCP process excellent performance. The sensitivity and AUC of DCP (0.60, 0.74, respectively) were higher than AFP (0.34, 0.59, respectively). The network meta-analysis showed that DCP and GALAD score had similar performance. In detecting all-stage NAFLD-related HCC, GALAD score (sensitivity = 0.87; YI = 0.77) performed better than AFP (sensitivity = 0.56; YI = 0.50), AFP-L3 (sensitivity = 0.39; YI = 0.36) and DCP (sensitivity = 0.73; YI = 0.62). Network meta-analysis obtained consistent results with conventional meta-analysis. CONCLUSIONS Due to the lower cost-effectiveness, DCP was more suitable for detecting early NAFLD-related HCC. AFP could be used in detecting all-stage NAFLD-related HCC.
Collapse
Affiliation(s)
- Han Li
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Hui Liu
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Lun-Jie Yan
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Zi-Niu Ding
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Xiao Zhang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Guo-Qiang Pan
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Cheng-Long Han
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Bao-Wen Tian
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Si-Yu Tan
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Zhao-Ru Dong
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Dong-Xu Wang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Yu-Chuan Yan
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Tao Li
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| |
Collapse
|
8
|
Apostolos A, Chlorogiannis D, Vasilagkos G, Katsanos K, Toutouzas K, Aminian A, Alexopoulos D, Davlouros P, Tsigkas G. Safety and efficacy of shortened dual antiplatelet therapy after complex percutaneous coronary intervention: A systematic review and meta-analysis. Hellenic J Cardiol 2023; 71:33-41. [PMID: 36736730 DOI: 10.1016/j.hjc.2023.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/07/2023] [Accepted: 01/25/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Optimal duration of dual antiplatelet therapy (DAPT) in patients undergoing complex percutaneous coronary intervention (PCI) remains under investigation. Our aim is to compare shortened (≤3 months) DAPT with longer DAPT in patients undergoing complex PCIs. METHODS Three major databases (MEDLINE, Cochrane Central Register of Controlled Trials, and Scopus) were screened. The primary endpoint was major bleedings as they are defined by the Bleeding Academic Research Consortium (BARC) 3-5. The secondary endpoints were major adverse cardiovascular events, all-cause and cardiovascular mortality, myocardial infarction, stroke, and stent thrombosis. RESULTS Five studies were included in our analysis, with a total of 9,115 patients. Our meta-analysis met its primary endpoint, as abbreviated DAPT significantly reduced major bleedings by 43% (95% confidence intervals: 0.35-0.93). Ischemic events and mortality were not affected by the shortening of DAPT. CONCLUSION Shortened DAPT significantly reduced the odds of major bleedings in patients undergoing complex PCI without increasing the ischemic events or mortality. Thus, it could be considered a safe and feasible option in such patients.
Collapse
Affiliation(s)
- Anastasios Apostolos
- Department of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece; First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece.
| | - Dimitrios Chlorogiannis
- Department of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| | - Georgios Vasilagkos
- Department of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| | - Konstantinos Katsanos
- Department of Interventional Radiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Periklis Davlouros
- Department of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece.
| |
Collapse
|
9
|
El Alaoui El Abdallaoui O, Tornyos D, Lukács R, Komócsi A. Abatement of potent P2Y12 antagonist-based dual antiplatelet therapy after coronary intervention: A network meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 9:1008914. [PMID: 36712280 PMCID: PMC9877531 DOI: 10.3389/fcvm.2022.1008914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023] Open
Abstract
Introduction Dual antiplatelet therapy (DAPT) including prasugrel or ticagrelor is recommended in patients with acute coronary syndromes (ACS) treated with coronary intervention (PCI). Acknowledging the importance of bleeding, multiple trials tested abatement schemes including uniform or guided de-escalation from the potent P2Y12 inhibitor (P2Y12-De) or P2Y12 inhibitor monotherapy (P2Y12-Mo) with heterogeneous results. We aimed to perform a systematic review and network meta-analysis of the impact of DAPT abatement strategies in patients with PCI. Methods Electronic databases were searched for relevant randomized clinical studies evaluating clinical outcomes of patients after PCI. The rate of adverse events was evaluated using a frequentist network metanalysis. The random-effects model was used to combine risk estimates across trials and risk ratio (RR) with 95% confidence intervals (95% CIs) served as summary statistics. The primary endpoints of interest were the rate of major cardiac adverse events (MACE, defined as the composite of cardiovascular mortality, myocardial infarction and stroke) and bleeding. Results Ten studies were identified randomizing 42511 patients. 6359 switched to the P2Y12-De and 13062 switched to the P2Y12-Mo. The risk of MACE, reflected a 24% reduction in the P2Y12-De and a 14% in the P2Y12-Mo in comparison with the DAPT strategy using potent P2Y12 inhibitors (RR: 0.76 [0.62, 0.94], and RR: 0.86 [0.75, 0.99], p < 0.05 both). A 35% risk reduction of major bleeding was seen with monotherapy (RR: 0.65 [0.46, 0.91],) contrasting the de-escalation trials where this effect was not significant (RR: 0.84 [0.57, 1.22]). All bleeding and minor bleeding events were reduced with both strategies. Indirect P2Y12-Mo versus P2Y12-De comparisons exhibited them as similar alternatives without significant differences. Conclusion Our analysis suggests that both P2Y12-De and P2Y12-Mo reduce ischemic events and bleeding among PCI-treated ACS patients. Ischemic benefit was more expressed with P2Y12-De, however, reduction of major bleeding was only significant with P2Y12-Mo strategy. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021258502, identifier CRD42021258502.
Collapse
Affiliation(s)
| | - Dániel Tornyos
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Réka Lukács
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - András Komócsi
- Department of Interventional Cardiology, Heart Institute, Medical School, University of Pécs, Pécs, Hungary,*Correspondence: András Komócsi ✉
| |
Collapse
|
10
|
Tsigkas G, Apostolos A, Trigka A, Chlorogiannis D, Katsanos K, Toutouzas K, Alexopoulos D, Brilakis ES, Davlouros P. Very Short Versus Longer Dual Antiplatelet Treatment After Coronary Interventions: A Systematic Review and Meta-analysis. Am J Cardiovasc Drugs 2023; 23:35-46. [PMID: 36536171 PMCID: PMC9845152 DOI: 10.1007/s40256-022-00559-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Very short (≤ 3 months) duration of dual antiplatelet therapy (VSDAPT) has recently been proposed after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). OBJECTIVES The aim of this systematic review and meta-analysis was to compare very short versus > 3 months' duration of dual antiplatelet treatment (DAPT) in patients undergoing PCI with DES, focusing on ischemic and bleeding events. METHODS Three major databases (Medline, Cochrane Central Register of Controlled Trials, and Scopus) were screened for eligible randomized controlled trials (RCTs). The primary endpoint of our meta-analysis was the incidence of net adverse clinical events (NACE), as defined per trial, while secondary endpoints were major adverse cardiovascular events (MACE), all-cause and cardiovascular mortality, myocardial infarction, stroke, stent thrombosis, repeat revascularization, and major bleeding. RESULTS We included eight RCTs with a total of 41,204 patients; 20,592 patients were allocated to VSDAPT and the remaining 20,612 patients were randomized to a longer DAPT period. The abbreviated regimen significantly reduced NACE (odds ratio [OR] 0.83, 95% confidence interval [Cl] 0.74-0.95) and major bleeding (OR 0.71, 95% Cl 0.61-0.82), without affecting mortality or ischemic events (stroke, myocardial infarction, revascularization, and stent thrombosis). CONCLUSIONS VSDAPT significantly decreased the odds of NACEs and major bleeding by 17% and 29%, respectively, without increasing ischemic events. Thus, VSDAPT could be well tolerated and feasible after PCI with DES. CLINICAL TRIALS REGISTRATION Open Science Framework (10.17605/OSF.IO/4H2JB) Very short-term DAPT significantly reduces NACE and major bleedings, without affecting mortality and ischemic events (MACE, MI, stroke, stent thrombosis and revascularization). CI confidence intervals, DAPT dual antiplatelet therapy, DES drug-eluting stents, MACE major adverse cardiovascular events, MI myocardial infarction, NACE net adverse clinical events, OR odds ratio, PCI percutaneous coronary interventions.
Collapse
Affiliation(s)
- Grigorios Tsigkas
- grid.412458.eDepartment of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| | - Anastasios Apostolos
- grid.412458.eDepartment of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece ,grid.414122.00000 0004 0621 2899First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Aikaterini Trigka
- grid.412458.eDepartment of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| | - Dimitrios Chlorogiannis
- grid.412458.eDepartment of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| | - Konstantinos Katsanos
- grid.412458.eDepartment of Interventional Radiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| | - Konstantinos Toutouzas
- grid.414122.00000 0004 0621 2899First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Dimitrios Alexopoulos
- grid.5216.00000 0001 2155 0800Second Department of Cardiology, Medical School, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Emmanouil S. Brilakis
- grid.480845.50000 0004 0629 5065Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, MN USA
| | - Periklis Davlouros
- grid.412458.eDepartment of Cardiology, Faculty of Medicine, University of Patras, University Hospital of Patras, Patras, Greece
| |
Collapse
|
11
|
Tam CC, Tse HF. Antiplatelet Therapy Aims and Strategies in Asian Patients with Acute Coronary Syndrome or Stable Coronary Artery Disease. J Clin Med 2022; 11:jcm11247440. [PMID: 36556067 PMCID: PMC9784545 DOI: 10.3390/jcm11247440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) has been the mainstay treatment to reduce ischemic events, such as myocardial infarction or stroke, in patients with coronary artery disease (CAD). The development of potent P2Y12 inhibitors (ticagrelor and prasugrel) has helped to further reduce ischemic events, particularly among high-risk patients. Meanwhile, the evolution of newer generations of drug-eluting stents are also improving outcomes of percutaneous coronary intervention. Research studies on antiplatelet therapy in recent years have focused on balancing ischemic and bleeding risks through different strategies, which include P2Y12 inhibitor monotherapy, escalation and de-escalation, and extended DAPT. Because results from the large number of clinical studies may sometimes appear conflicting, this review aims to summarize recent advances, and demonstrate that they are aligned by a general principle, namely, strategies may be adopted based on treatment aims for specific patients at several time points. Another aim of this review is to outline the important considerations for using antiplatelet therapy in Asian patients, in whom there is a greater prevalence of CYP2C19 loss-of-function mutations, and a common increased risk of bleeding, despite high platelet reactivity (the so-called "East Asian Paradox").
Collapse
Affiliation(s)
- Chor-Cheung Tam
- Division of Cardiology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
- Correspondence:
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| |
Collapse
|