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Reduced Mortality With Antiplatelet Therapy Deescalation After Percutaneous Coronary Intervention in Acute Coronary
Tullio Palmerini1, Antonio Giulio Bruno1, Mauro Gasparini2
1Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (T.P., A.G.B., N.T., E.N., F.S., M.O., F.C., G.G., N.G.).
Insights
Deescalating potent dual antiplatelet therapy (DAPT) after 1-3 months in acute coronary syndrome patients reduces mortality and bleeding. This strategy maintains similar rates of major adverse cardiovascular events compared to standard 1-year DAPT.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) is standard for acute coronary syndromes (ACS) post-percutaneous coronary intervention (PCI).
- Deescalation of potent DAPT is explored to reduce bleeding risk in low-risk patients.
- Uncertainty exists regarding the preservation of ischemic and survival benefits with deescalation therapy.
Approach:
- A pairwise meta-analysis of randomized trials was conducted.
- Included patients with ACS undergoing PCI, comparing 1-year standard potent DAPT versus deescalation therapy (1-3 months potent DAPT followed by reduced potency or monotherapy).
- Searched MEDLINE, EMBASE, Cochrane databases, and international meeting proceedings for relevant trials.
Key Points:
- The meta-analysis included 6 trials with 20,837 patients.
- Deescalation therapy showed lower 1-year all-cause mortality (OR 0.75, P=0.02).
- Deescalation therapy significantly reduced major bleeding (OR 0.59, P<0.0001) with no difference in major adverse cardiovascular events (OR 0.89, P=0.14).
Conclusions:
- Antiplatelet therapy deescalation after 1-3 months is associated with decreased mortality and major bleeding in low bleeding risk ACS patients undergoing PCI.
- This approach offers similar rates of major adverse cardiovascular events compared to 1-year potent DAPT.
- Deescalation therapy represents a viable alternative to standard potent DAPT for selected ACS patients.
Background:
Antiplatelet therapy deescalation has been suggested as an alternative to standard treatment with potent dual antiplatelet therapy (DAPT) for 1 year in low bleeding risk patients with acute coronary syndromes undergoing percutaneous coronary intervention to mitigate the increased risk of bleeding. Whether this strategy preserves the ischemic and survival benefits of potent DAPT is uncertain.
Methods:
We performed a pairwise meta-analysis in patients with acute coronary syndrome undergoing percutaneous coronary intervention treated with either 1-year standard potent DAPT versus deescalation therapy (potent DAPT for 1-3 months followed by either reduced potency DAPT or ticagrelor monotherapy for up to 1 year). Randomized trials comparing standard DAPT versus deescalation therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. The primary end point was 1-year all-cause mortality.
Results:
The meta-analysis included 6 trials in which 20 837 patients were randomized to potent DAPT for 1 to 3 months followed by deescalation therapy for up to 1 year (n=10 392) or standard potent DAPT for 1 year (n=10 445). Deescalation therapy was associated with lower 1-year rates of all-cause mortality compared with standard therapy (odds ratio, 0.75 [95% CI, 0.59-0.95]; P=0.02). Deescalation therapy was also associated with lower rates of major bleeding (odds ratio, 0.59 [95% CI, 0.48-0.72]; P<0.0001), with no significant difference in major adverse cardiac events (major adverse cardiovascular events; odds ratio, 0.89 [95% CI, 0.77-1.04]; P=0.14).
Conclusions:
In low bleeding risk patients with acute coronary syndrome undergoing percutaneous coronary intervention, compared with 1-year of potent DAPT, antiplatelet therapy deescalation therapy after 1 to 3 months was associated with decreased mortality and major bleeding with similar rates of major adverse cardiovascular events.
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