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Antiplatelet Strategy for Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention:
Waqas Ullah1, Harigopal Sandhyavenu2, Amro Taha3
1Thomas Jefferson University Hospitals Philadelphia PA.
Insights
Optimal antiplatelet therapy for acute coronary syndrome after percutaneous coronary intervention involves a 3-month aspirin and ticagrelor regimen. This strategy reduces major adverse cardiovascular events without increasing bleeding risk.
Area of Science:
- Cardiology
- Pharmacology
- Interventional Cardiology
Background:
- Optimal antiplatelet therapy duration and choice post-percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) is debated.
- Current guidelines lack definitive recommendations for specific antiplatelet strategies.
Purpose of the Study:
- To compare the safety and efficacy of various dual-antiplatelet therapy (DAPT) regimens in ACS patients undergoing PCI.
- To identify the optimal antiplatelet strategy to minimize major adverse cardiovascular events (MACE) and bleeding.
Main Methods:
- A systematic review and network meta-analysis of 32 randomized controlled trials involving over 100,000 patients.
- Comparison of 12-month DAPT with aspirin and clopidogrel against alternative strategies including high-potency, low-dose, and short-duration DAPT.
Main Results:
- High- to low-potency DAPT and 12-month aspirin+prasugrel DAPT showed lower MACE compared to standard 12-month DAPT.
- 1-month DAPT followed by clopidogrel only increased MACE.
- 12-month DAPT with prasugrel or ticagrelor increased bleeding risk; high- to low-potency DAPT did not significantly increase bleeding.
Conclusions:
- A 3-month regimen of aspirin and ticagrelor, followed by aspirin and clopidogrel, is proposed as an optimal strategy.
- This regimen significantly reduces MACE in post-PCI ACS patients without elevating bleeding risk.
Background:
Optimal duration and choice of antiplatelet therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention remain controversial.
Methods And Results:
Digital databases (PubMed, Cochrane, and Embase) were queried to select all randomized controlled trials on a post-percutaneous coronary intervention population with acute coronary syndrome. Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel for 12 months was compared with 4 major strategies: high-potency, high- to low-potency, low-dose, and short-duration DAPT. A network meta-analysis was performed to compare the safety and efficacy of different antiplatelet strategies. This study was the second updated manuscript under the International Prospective Register of Systematic Review registration (CRD42021286552). Thirty-two randomized controlled trials comprising 103 459 (51 750 experimental, 51 709 control) patients were included. Compared with DAPT with aspirin and clopidogrel for 12 months, high- to low-potency DAPT (risk ratio [RR], 0.69 [95% CI, 0.52-0.92]) and aspirin+prasugrel containing DAPT for 12 months (RR, 0.84 [95% CI, 0.72-0.98]) had a significantly lower, whereas DAPT for 1 month followed by clopidogrel only (RR, 1.59 [95% CI, 1.06-2.39]) had a higher, incidence of major adverse cardiovascular events at 1 year (median follow-up). Prasugrel (RR, 1.35 [95% CI, 1.09-1.66]) and ticagrelor (RR, 1.38 [95% CI, 1.17-1.62]) containing DAPT for 12 months had significantly higher rates, whereas high- to low-potency DAPT (RR, 0.85 [95% CI, 0.63-1.15]) had no significant risk of major bleeding.
Conclusions:
Aspirin and ticagrelor for 3 months, followed by aspirin and clopidogrel for the remaining duration, can be considered the optimal strategy for treating post-percutaneous coronary intervention patients with acute coronary syndrome because of a significantly reduced risk of major adverse cardiovascular events without increasing the risk of bleeding.
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