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De Filippo O, Piroli F, Bruno F, Bocchino PP, Saglietto A, Franchin L, Angelini F, Gallone G, Rizzello G, Ahmad M, Gasparini M, Chatterjee S, De Ferrari GM, D'Ascenzo F. De-escalation of dual antiplatelet therapy for patients with acute coronary syndrome after percutaneous coronary intervention: a systematic review and network meta-analysis. BMJ Evid Based Med 2024; 29:171-186. [PMID: 38242567 DOI: 10.1136/bmjebm-2023-112476] [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] [Accepted: 12/25/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVES To compare dual antiplatelet therapy (DAPT) de-escalation with five alternative DAPT strategies in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). DESIGN We conducted a systematic review and network meta-analysis (NMA). Parallel-arm randomised controlled trials (RCTs) comparing DAPT strategies were included and arms of interest were compared via NMA. Partial ranking of each identified arm and for each investigated endpoint was also performed. SETTING AND PARTICIPANTS Adult patients with ACS (≥18 years) undergoing PCI with indications for DAPT. SEARCH METHODS A comprehensive search covered several databases (PubMed, Embase, Cochrane Central, MEDLINE, Conference Proceeding Citation Index-Science) from inception to 15 October 2023. Medical subject headings and keywords related to ACS, PCI and DAPT interventions were used. Reference lists of included studies were screened. Clinical trials registers were searched for ongoing or unpublished trials. INTERVENTIONS Six strategies were assessed: T1 arm: acetylsalicylic acid (ASA) and prasugrel for 12 months; T2 arm: ASA and low-dose prasugrel for 12 months; T3 arm: ASA and ticagrelor for 12 months; T4 arm: DAPT de-escalation (ASA+P2Y12 inhibitor for 1-3 months, then single antiplatelet therapy with potent P2Y12 inhibitor or DAPT with clopidogrel); T5 arm: ASA and clopidogrel for 12 months; T6 arm: ASA and clopidogrel for 3-6 months. MAIN OUTCOME MEASURES Primary outcome: Cardiovascular mortality. SECONDARY OUTCOMES bleeding events (all, major, minor), stent thrombosis (ST), stroke, myocardial infarction (MI), all-cause mortality, major adverse cardiovascular events (MACE). RESULTS 23 RCTs (75 064 patients with ACS) were included. No differences in cardiovascular mortality, all-cause death, recurrent MI or MACE were found when the six strategies were compared, although with different levels of certainty of evidence. ASA and clopidogrel for 12 or 3-6 months may result in a large increase of ST risk versus ASA plus full-dose prasugrel (OR 2.00, 95% CI 1.14 to 3.12, and OR 3.42, 95% CI 1.33 to 7.26, respectively; low certainty evidence for both comparisons). DAPT de-escalation probably results in a reduced risk of all bleedings compared with ASA plus full-dose 12-month prasugrel (OR 0.49, 95% CI 0.26 to 0.81, moderate-certainty evidence) and ASA plus 12-month ticagrelor (OR 0.52, 95% CI 0.33 to 0.75), while it may not increase the risk of ST. ASA plus 12-month clopidogrel may reduce all bleedings versus ASA plus full-dose 12-month prasugrel (OR 0.66, 95% CI 0.42 to 0.94, low certainty) and ASA plus 12-month ticagrelor (OR 0.70, 95% CI 0.52 to 0.89). CONCLUSIONS DAPT de-escalation and ASA-clopidogrel regimens may reduce bleeding events compared with 12 months ASA and potent P2Y12 inhibitors. 3-6 months or 12-month aspirin-clopidogrel may increase ST risk compared with 12-month aspirin plus potent P2Y12 inhibitors, while DAPT de-escalation probably does not.
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Affiliation(s)
- Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesco Piroli
- S.O.C. Cardiologia Ospedaliera, Presidio Ospedaliero Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia - IRCCS, Reggio Emilia, Italy
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Andrea Saglietto
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Luca Franchin
- Cardiology Department, University Hospital 'Santa Maria della Misericordia', Azienda Sanitaria Universitaria Integrata Friuli Centrale (ASUFC), Udine, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giulia Rizzello
- Dipartimento di Scienze Matematiche (DISMA), Giuseppe Luigi Lagrange, Politecnico di Torino, Torino, Italy
| | | | - Mauro Gasparini
- Dipartimento di Scienze Matematiche (DISMA), Giuseppe Luigi Lagrange, Politecnico di Torino, Torino, Italy
| | - Saurav Chatterjee
- New York Community Hospital, Maimonides Health, Brooklyn, New York, USA
- Zucker School of Medicine, Hempstead, New York, USA
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
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Shah RP, Shafiq A, Hamza M, Maniya MT, Duhan S, Keisham B, Patel B, Alamzaib SM, Yashi K, Uppal D, Sattar Y, Tiwari D, Paul TK, AlJaroudi W, Alraies MC. Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis. Am J Cardiol 2023; 207:206-214. [PMID: 37751668 DOI: 10.1016/j.amjcard.2023.08.117] [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: 07/16/2023] [Revised: 08/16/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023]
Abstract
Limited data comparing prasugrel and ticagrelor in acute coronary syndrome are available. Online databases, including MEDLINE and Cochrane Central, were queried to compare these drugs. The primary outcomes of this meta-analysis are myocardial infarction (MI), all-cause mortality, cardiovascular mortality, noncardiovascular mortality, stent thrombosis, and stroke. The secondary outcome is major bleeding. A total of 9 studies, including 94,590 patients (prasugrel group = 32,759; ticagrelor group = 61,831), were included in this meta-analysis. The overall mean age was 62.73 years, whereas the mean age for the ticagrelor and prasugrel groups was 63.80 and 61.65 years, respectively. Prasugrel is equally effective as compared with ticagrelor in preventing MI. There was no difference between the 2 groups regarding all-cause mortality, stent thrombosis, stroke, or major bleeding. In patients with acute coronary syndrome, prasugrel is equally effective when compared with ticagrelor in preventing MI.
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Affiliation(s)
- Rajendra P Shah
- Department of Cardiology, University of Florida/Malcom Randall Veterans Affairs Medical Center, Florida, USA
| | - Aimen Shafiq
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mohammad Hamza
- Department of Medicine, Albany Medical Center, Albany, New York, USA
| | | | - Sanchit Duhan
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Bijeta Keisham
- Department of Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland, USA
| | - Bansari Patel
- Department of Medicine, West Virginia University, West Virginia, USA
| | | | - Kanica Yashi
- Department of Medicine, Bassett Healthcare, New York, USA
| | - Dipan Uppal
- Department of Cardiology, Cleveland Clinic Florida, Florida, USA
| | - Yasar Sattar
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - Dinesh Tiwari
- Department of Dermatology, Mayo Institute of Medical Sciences, Uttar Pradesh, India
| | - Timir K Paul
- Department of Cardiology, University of Tennessee Health Sciences Center, Nashville, Tennessee, USA
| | - Wael AlJaroudi
- Division of Cardiology, Medical College of Georgia at Augusta University Medical College of Georgia, Augusta, Georgia, USA
| | - M Chadi Alraies
- Department of Cardiology, Cardiovascular Institute, Detroit Medical Center, Detroit, Michigan, USA.
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Versaci F, Kufner S, Cassese S, Joner M, Mayer K, Xhepa E, Koch T, Wiebe J, Ibrahim T, Laugwitz KL, Schunkert H, Kastrati A, Byrne RA, Spagnoli A, Bernardi M, Spadafora L, Biondi-Zoccai G. Very long-term outlook of acute coronary syndromes after percutaneous coronary intervention with implantation of polymer-free versus durable-polymer new-generation drug-eluting stents. Minerva Med 2023; 114:590-600. [PMID: 37293892 DOI: 10.23736/s0026-4806.23.08684-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Detailed long-term follow-up data on patients with acute coronary syndromes (ACS) in general, and those with ST-elevation myocardial infarction (STEMI) in particular, are limited. We aimed to appraise the long-term outlook of patients undergoing percutaneous coronary intervention (PCI) with state-of-the-art coronary stents for STEMI, other types of ACS and stable coronary artery disease (CAD), and also explore the potential beneficial impact of new-generation polymer-free drug-eluting stents (DES) in this setting. METHODS Baseline, procedural and very long-term outcome data on patients undergoing PCI and randomized to implantation of new-generation polymer-free vs. durable polymer DES were systematically collected, explicitly distinguishing subjects with admission diagnosis of STEMI, non-ST-elevation ACS (NSTEACS), and stable CAD. Outcomes of interest included death, myocardial infarction, revascularization (i.e. patient-oriented composite endpoints [POCE]), major adverse cardiac events (MACE), and device-oriented composite endpoints (DOCE). RESULTS A total of 3002 patients were included, 1770 (59.0%) with stable CAD, 921 (30.7%) with NSTEACS, and 311 (10.4%) with STEMI. At long-term follow-up (7.5±3.1 years), all clinical events were significantly more common in the NSTEACS group and, to a lesser extent, in the stable CAD group (e.g. POCE occurred in, respectively, 637 [44.7%] vs. 964 [37.9%] vs. 133 [31.5%], P<0.001). While these differences were largely attributable to adverse coexisting features in patients with NSTEACS (e.g. advanced age, insulin-dependent diabetes, and extent of CAD), the unfavorable outlook of patients presenting with NSTEACS persisted even after multivariable adjustment including several prognostically relevant factors (hazard ratio [HR] of NSTEACS vs. stable CAD 1.19 [95% confidence interval 1.03-1.38], P=0.016). Notably, even after encompassing all prognostically impactful features, no difference between polymer-free and permanent polymer drug-eluting stents appeared (HR=0.96 [0.84-1.10], P=0.560). CONCLUSIONS Unstable coronary artery disease, especially when presenting without ST-elevation, represents an informative marker of adverse long-term prognosis in current state-of-the-art invasive cardiology practice. Even considering admission diagnosis, and despite of using no polymer, polymer-free DES showed similar results with regards to safety and efficacy when compared with DES with permanent polymer.
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Affiliation(s)
- Francesco Versaci
- UOC UTIC Emodinamica e Cardiologia, Santa Maria Goretti Hospital, Latina, Italy
| | - Sebastian Kufner
- Deutsches Herzzentrum München, Technische Universität München (TUM), Munich, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München (TUM), Munich, Germany
| | - Michael Joner
- Deutsches Herzzentrum München, Technische Universität München (TUM), Munich, Germany
- German Center for Cardiovascular Research, partner site Munich Heart Alliance, Munich, Germany
| | - Katharina Mayer
- Deutsches Herzzentrum München, Technische Universität München (TUM), Munich, Germany
| | - Erion Xhepa
- Deutsches Herzzentrum München, Technische Universität München (TUM), Munich, Germany
| | - Tobias Koch
- Deutsches Herzzentrum München, Technische Universität München (TUM), Munich, Germany
| | - Jens Wiebe
- Deutsches Herzzentrum München, Technische Universität München (TUM), Munich, Germany
| | - Tareq Ibrahim
- Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie und Pneumologie), Rechts der Isar Hospital, Technische Universität München (TUM), Munich, Germany
| | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research, partner site Munich Heart Alliance, Munich, Germany
- Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie und Pneumologie), Rechts der Isar Hospital, Technische Universität München (TUM), Munich, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München (TUM), Munich, Germany
- German Center for Cardiovascular Research, partner site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München (TUM), Munich, Germany
- German Center for Cardiovascular Research, partner site Munich Heart Alliance, Munich, Germany
| | - Robert A Byrne
- Dublin Cardiovascular Research Institute, Mater Private Hospital, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Alessandra Spagnoli
- Section of BioMedical Statistics, Department of Public Health and Infectious Disease, Sapienza University, Rome, Italy
| | - Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy -
- Mediterranea Cardiocentro, Naples, Italy
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De Filippo O, Russo C, Manai R, Borzillo I, Savoca F, Gallone G, Bruno F, Ahmad M, De Ferrari GM, D'Ascenzo F. Impact of secondary prevention medical therapies on outcomes of patients suffering from Myocardial Infarction with NonObstructive Coronary Artery disease (MINOCA): A meta-analysis. Int J Cardiol 2022; 368:1-9. [PMID: 35987312 DOI: 10.1016/j.ijcard.2022.08.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/11/2022] [Accepted: 08/15/2022] [Indexed: 11/19/2022]
Abstract
AIMS To assess the impact of secondary prevention medical therapies (statins, ACE-inhibitors/Angiotensin Receptor Blockers (ARB), beta-blockers (BB) and Dual Antiplatelet Therapy (DAPT)) on outcomes of patients with myocardial infarction with nonobstructive coronary artery disease (MINOCA). METHODS Five adjusted observational studies encompassing 10,546 were included in this meta-analysis. All-cause death was the primary endpoint, while Major Adverse Cardiovascular Events (MACE) and acute myocardial infarction (AMI) were the secondary endpoints. RESULTS After 24 months of follow up, statins (tested in 8093 patients) were associated with a reduced risk of all-cause death (HR 0.60:0.45-0.81, p 〈0,001), while ACE-inhibitors/ARB (on 9666 patients) were not. Aggregate data from two studies (n = 9720, 7719 on beta-blockers, 6423 on DAPT) indicated that beta-blockers and DAPT (median follow-up 34.1 and 15.7 months, respectively) were both associated with a significant reduction of all-cause death (HR0.81:0.66-0.99, p = 0.04, and HR0.73:0.55-0.98, p = 0.03, for beta-blockers and DAPT, respectively). Among the investigated therapies, only ACE-inhibitors/ARBs entailed a reduced risk of MACE (HR0.65:0.44-0.94, p = 0.02, all CI 95%) over 36.5 months (four studies, n = 10,150). None of the investigated therapies was associated with a reduced risk of AMI. CONCLUSIONS Data from adjusted observational studies suggest that beta-blockers, statins and DAPT are associated with a survival benefit among MINOCA patients. ACE-inhibitors/ARB entail a reduced risk of MACE while none of the investigated secondary prevention therapies is associated with a reduced risk of AMI. Randomized controlled trials are warranted to confirm these findings.
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Affiliation(s)
- Ovidio De Filippo
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy.
| | - Caterina Russo
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Rossella Manai
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Irene Borzillo
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Federica Savoca
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Guglielmo Gallone
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Francesco Bruno
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Mahmood Ahmad
- Department of Cardiology, Royal Free Hospital, London, United Kingdom
| | - Gaetano Maria De Ferrari
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
| | - Fabrizio D'Ascenzo
- Cardiovascular and thoracic department, A.O.U. Città della Salute e della Scienza, Turin, Italy and Department of Medical Sciences, University of Turin, Italy
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