Mortality of Escalation and Modulation Antithrombotic Therapy in Coronary Artery Disease Patients: A Meta-analysis of
Qiao-Yu Shao1, Zhi-Jian Wang1, Xiao-Teng Ma1
1Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
Insights
Modulating or escalating antithrombotic therapy (ATT) shows minimal impact on all-cause mortality. However, modulation reduces bleeding risk, while escalation increases it, with no significant effect on myocardial infarction.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Antithrombotic therapy (ATT) clinical benefit is a balance between ischemic events and bleeding.
- Assessing the impact of ATT modulation or escalation on mortality and clinical events is crucial.
Approach:
- A meta-analysis of 32 randomized controlled trials involving 160,659 patients with coronary artery disease was conducted.
- Compared escalation or modulation of ATT against standard ATT.
Key Points:
- Neither ATT escalation nor modulation significantly affected all-cause mortality.
- Escalation reduced myocardial infarction risk but increased major/minor bleeding.
- Modulation showed similar myocardial infarction risk but significantly reduced major/minor bleeding.
Conclusions:
- ATT escalation or modulation offers little benefit for all-cause mortality.
- Variability in all-cause mortality outcomes was primarily linked to bleeding events, not myocardial infarction.
Background:
The net clinical benefit of antithrombotic therapy (ATT) reflects the concomitant effects of bleeding and ischemic events.
Objectives:
We sought to assess the overall effect of the modulation or escalation of ATT on all-cause mortality as well as ischemic and bleeding events.
Methods:
We performed a meta-analysis of randomized controlled trials comparing escalation or modulation of ATT versus standard ATT in patients with coronary artery disease. A total of 32 studies with 160,659 subjects were enrolled in this analysis.
Results:
Neither escalation nor modulation of ATT has significant effect on all-cause mortality (escalation: relative risk [RR]: 0.94, 95% confidence interval [CI]: 0.85-1.04; modulation: RR: 0.90; 95% CI: 0.81-1.01). Compared with standard ATT therapy, escalation of ATT was associated with lower risk of myocardial infarction (MI; RR: 0.84, 95% CI: 0.76-0.94), but had a higher risk of major or minor bleeding (RR: 1.38, 95% CI: 1.15-1.66). Modulation of ATT was associated with a similar risk of MI (RR: 1.07, 95% CI: 0.96-1.19), but a reduced risk for major or minor bleeding (RR: 0.58, 95% CI: 0.51-0.66). Meta-regression combining both escalation and modulation studies found that the heterogeneity of all-cause mortality was mainly attributed to the heterogeneity of major or minor bleeding (adjusted R-squared = 100.00%, p = 0.004), but not to MI.
Conclusion:
Either escalation or modulation of ATT has little benefit in all-cause mortality. The variability of the treatment effects on all-cause mortality was mainly attributed to the variability of major or minor bleeding, but not to MI.
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