Comparative efficacy and safety of oral P2Y₁₂inhibitors after non-ST-elevation acute coronary syndromes: a network meta-analysis

Abstract

BackgroundCurrently, potent P2Y12 inhibition with the use of prasugrel or ticagrelor is the mainstay of treatment after an acute coronary syndrome (ACS). The 2020 European Society of Cardiology (ESC) Guidelines recommend the use of prasugrel over ticagrelor in patients with non-ST-elevation ACS (NSTE-ACS) intended to receive invasive management (class IIa recommendation), however there are contradictory views regarding this recommendation.AimTo compare oral P2Y12 inhibitors in NSTE-ACS in terms of efficacy and safety with a focus on patients intended to proceed to invasive management.MethodsWe systematically searched PubMed, Cochrane Central Register of Controlled Trials and Web of Science to identify studies that compared different oral P2Y12 inhibitors (clopidogrel, prasugrel and ticagrelor) in patients with NSTE-ACS. Efficacy outcomes included the major adverse cardiovascular events outcome and safety outcomes included minor and major bleedings. We performed a frequentist network meta-analysis.ResultsNine studies (n=35 441 patients) were included in the systematic review. There was no difference between prasugrel and ticagrelor in the composite cardiovascular end point (prasugrel vs ticagrelor HR=0.80, 95% CI=0.61 to 1.06) in all patients with NSTE-ACS. In patients intended to receive invasive management, prasugrel resulted in a reduction of the composite cardiovascular end point both versus clopidogrel (HR=0.76, 95% CI=0.61 to 0.95) and ticagrelor (HR=0.74, 95% CI=0.56 to 0.98). Inconsistency was moderate and non-significant (I2=27%, total Q p=0.2). Prasugrel ranked as the most efficient treatment in the composite cardiovascular efficacy outcome, all-cause death, myocardial infarction and definite stent thrombosis, while clopidogrel ranked as safest in the bleeding outcomes.ConclusionIn patients with NSTE-ACS intended to receive invasive management, an antiplatelet strategy based on prasugrel is more efficient than a similar strategy based on ticagrelor on a moderate level of evidence. This analysis supports the current recommendations by the ESC guidelines.

Effect of prasugrel versus ticagrelor on coronary microcirculation in patients undergoing pharmacoinvasive strategy – acute and short-term results

“…Our study results are also in agreement with the metanalysis published by Farmakis IT et al in patients of NSTEMI treated with P 2 Y 12 inhibitors which supports the use of prasugrel over ticagrelor as a more efficient strategy [28]. So we feel that for patients undergoing a pharmacoinvasive strategy following successful thrombolysis, prasugrel should be preferred over ticagrelor if patients have no contraindication to therapy with prasugrel.…”

Potent P2Y12 Inhibitor Selection and De-escalation Strategies in Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention: Systematic Review and Meta-analysis

“…1 ). 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 From these systematic reviews, we identified 6 relevant RCTs. 14 , 24 , 25 , 26 , 27 , 28 We updated the search strategy from the most recent and comprehensive systematic review 15 to November 2022.…”

“…Farmakis et al. 23 found that, in non ST-elevation-ACS patients, prasugrel-based DAPT is more efficacious than ticagrelor-based DAPT, whereas Fong et al. 21 found that, in ACS patients, prasugrel- and ticagrelor-based DAPT had a similar efficacy as ticagrelor-based DAPT.…”