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P2Y12 Inhibitor or Aspirin Monotherapy for Secondary Prevention of Coronary Events
Felice Gragnano1, Davide Cao2, Leah Pirondini3
1Department of Translational Medical Science, University of Campania Luigi Vanvitelli, Naples, Italy; Division of Cardiology, Sant'Anna and San Sebastiano Hospital, Caserta, Italy.
Insights
P2Y12 inhibitor monotherapy is more effective than aspirin for preventing cardiovascular events in coronary artery disease patients. This approach shows superior efficacy with similar safety, suggesting it may be preferred for long-term secondary prevention.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Trials
Background:
- Aspirin is the standard for long-term cardiovascular event prevention in coronary artery disease (CAD).
- Evidence comparing aspirin to alternative antiplatelet agents like P2Y12 inhibitors is inconsistent.
Conclusions:
- P2Y12 inhibitor monotherapy demonstrates superior efficacy over aspirin monotherapy for secondary prevention in CAD.
- With comparable safety, P2Y12 inhibitors may be the preferred long-term treatment option.
Background:
Aspirin is the only antiplatelet agent with a Class I recommendation for long-term prevention of cardiovascular events in patients with coronary artery disease (CAD). There is inconsistent evidence on how it compares with alternative antiplatelet agents.
Objectives:
This study compared P2Y12 inhibitor monotherapy vs aspirin in patients with CAD.
Methods:
We conducted a patient-level meta-analysis of randomized trials comparing P2Y12 inhibitor monotherapy vs aspirin monotherapy for the prevention of cardiovascular events in patients with established CAD. The primary outcome was the composite of cardiovascular death, myocardial infarction, and stroke. Prespecified key secondary outcomes were major bleeding and net adverse clinical events (the composite of the primary outcome and major bleeding). Data were pooled in a 1-step meta-analysis.
Results:
Patient-level data were obtained from 7 trials. Overall, 24,325 participants were available for analysis, including 12,178 patients assigned to receive P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 assigned to receive aspirin. Risk of the primary outcome was lower with P2Y12 inhibitor monotherapy compared with aspirin over 2 years (HR: 0.88; 95% CI: 0.79-0.97; P = 0.012), mainly owing to less myocardial infarction (HR: 0.77; 95% CI: 0.66-0.90; P < 0.001). Major bleeding was similar (HR: 0.87; 95% CI: 0.70-1.09; P = 0.23) and net adverse clinical events were lower (HR: 0.89; 95% CI: 0.81-0.98; P = 0.020) with P2Y12 inhibitors. The treatment effect was consistent across prespecified subgroups and types of P2Y12 inhibitors.
Conclusions:
Given its superior efficacy and similar overall safety, P2Y12 inhibitor monotherapy might be preferred over aspirin monotherapy for long-term secondary prevention in patients with established CAD. (P2Y12 Inhibitor or Aspirin Monotherapy as Secondary Prevention in Patients With Coronary Artery Disease: An Individual Patient Data Meta-Analysis of Randomized Trials [PANTHER collaborative initiative]; CRD42021290774).
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