De-Escalation of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndromes

Shoji, Shuichi; Kuno, Toshiki; Fujisaki, Tomohiro; Takagi, Hisato; Briasoulis, Αlexandros; Deharo, Pierre; Cuisset, Thomas; Latib, Azeem; Kohsaka, Shun

doi:10.1016/j.jacc.2021.06.012

Cited by 52 publications

(43 citation statements)

References 41 publications

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“…Two recent meta-analyses reported that, as compared with standard therapy, de-escalation was associated with a safety benefit limited to lower minor bleeding complications and similar efficacy in preventing MACE. 23 24 Notably, the latest, large-sized studies on the topic were not included in these meta-analyses, as was not published yet. Moreover, Guo et al's meta-analysis pooled together data from both randomized and observational investigations, where patients had variable indications to de-escalation (unguided vs. platelet function-guided vs. economically motivated, whereas studies on genotype-guided de-escalation were not considered), and the findings on MACE rates were affected by a substantial amount of heterogeneity.…”

Section: Discussionmentioning

confidence: 99%

“…(16)(17)(18)(19)(20)(21)(22)(23)(24) In aggregate, these studies showed a reduction in minor bleeding with the former approaches. (15,16,20,23,24) However, single investigations may be individually undersized for events at low incidences, such as major bleeding.…”

Section: Introductionmentioning

confidence: 88%

“…[16][17][18][19][20][21][22][23][24] In aggregate, these studies showed a reduction in minor bleeding with the former approaches. 15,16,20,23,24 However, single investigations may be individually undersized for events at low incidences, such as major bleeding. Furthermore, in these trials, the sample size was not powered for ischemic endpoints, and therefore the efficacy of de-escalation or guided clopidogrel therapy in preventing thrombotic complications remains a matter of debate.…”

Section: Introductionmentioning

confidence: 88%

“…15 Randomized clinical trials have compared the abovementioned two alternative strategies of selective clopidogrel treatment (some studies focused on de-escalation, others on guided therapy) versus conventional antiplatelet treatment in patients undergoing PCI. [16][17][18][19][20][21][22][23][24] In aggregate, these studies showed a reduction in minor bleeding with the former approaches. 15,16,20,23,24 However, single investigations may be individually undersized for events at low incidences, such as major bleeding.…”

Section: Introductionmentioning

confidence: 88%

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Safety and Efficacy of Selective, Clopidogrel-Based Strategies in Acute Coronary Syndrome: A Study-Level Meta-analysis

et al. 2022

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Objectives. To investigate outcome with selective, clopidogrel-based therapies vs conventional treatment in patients undergoing percutaneous coronary intervention (PCI), especially for acute coronary syndrome. Background. Safety and efficacy of alternative, selective, clopidogrel-based therapies after PCI are not robustly established. Methods. We performed a study-level meta-analysis on six randomized trials investigating selective clopidogrel-based therapies (three on unguided de-escalation, N=3,473; three on guided clopidogrel therapy, N=7,533). Control groups received ticagrelor or prasugrel treatment. Main endpoints were major bleeding, any bleeding, major adverse cardiovascular events (MACE) and net clinical endpoint. Results. The incidence of major bleeding and MACE was similar in the selective, clopidogrel-based therapy vs conventional treatment arm (OR 0·72, 95% CI 0·51-1·01, p=0·06; OR 0·93, 0·72-1·20, p=0·58; respectively). The rates of any bleeding were lower in the selective, clopidogrel-based therapy vs conventional treatment group (OR 0·57, 0·40-0·80, p=0·001); this greater safety was significant for unguided de-escalation (OR 0·43, 0·32-0·58, p=0·00001) and non-significant for guided clopidogrel therapy (OR 0·72, 0·51-1·02, p=0·07; p for interaction 0·03). The incidence of the net clinical endpoint was fewer in the selective, clopidogrel-based therapy vs conventional treatment arm (OR 0·59, 0·41-0·85, p=0·004); this benefit was significant for unguided de-escalation (OR 0·50, 0·39-0·64, p<0·00001) and non-significant for guided clopidogrel therapy (OR 0·85, 0·62-1·16, p=0·30; p for interaction 0·01). Conclusions. As compared with prasugrel/ticagrelor treatment, alternative, selective, clopidogrel-based approaches provide a similar protection from cardiovascular events, reduce the risk of any bleeding and are associated with a greater net benefit. These beneficial effects were prevalent with unguided de-escalation to clopidogrel.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 88%

Section: Introductionmentioning

confidence: 88%

Section: Introductionmentioning

confidence: 88%

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Safety and Efficacy of Selective, Clopidogrel-Based Strategies in Acute Coronary Syndrome: A Study-Level Meta-analysis

et al. 2022

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“…Therefore, as stated by Galli et al in their meta-analysis, a genetically-guided choice of P2Y 12 inhibitor might provide the ideal combination of safety and efficacy [ 139 ]. It should be noted that the de-escalation of anti-platelet therapy from prasugrel or ticagrelor to clopidogrel might be associated with a net clinical benefit in patients treated with percutaneous coronary intervention following an acute coronary syndrome [ 140 ].…”

Section: Therapeutic Approachesmentioning

confidence: 99%

Factors Associated with Platelet Activation-Recent Pharmaceutical Approaches

Theofilis

Sagris

Oikonomou

et al. 2022

IJMS

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Platelets are at the forefront of human health and disease following the advances in their research presented in past decades. Platelet activation, their most crucial function, although beneficial in the case of vascular injury, may represent the initial step for thrombotic complications characterizing various pathologic states, primarily atherosclerotic cardiovascular diseases. In this review, we initially summarize the structural and functional characteristics of platelets. Next, we focus on the process of platelet activation and its associated factors, indicating the potential molecular mechanisms involving inflammation, endothelial dysfunction, and miRs. Finally, an overview of the available antiplatelet agents is being portrayed, together with agents possessing off-set platelet-inhibitory actions, while an extensive presentation of drugs under investigation is being given.

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The Need to Standardize Our Language Around Dual Antiplatelet Therapy—A Call to Action

2022

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De-Escalation of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndromes

Cited by 52 publications

References 41 publications

Safety and Efficacy of Selective, Clopidogrel-Based Strategies in Acute Coronary Syndrome: A Study-Level Meta-analysis

Safety and Efficacy of Selective, Clopidogrel-Based Strategies in Acute Coronary Syndrome: A Study-Level Meta-analysis

Factors Associated with Platelet Activation-Recent Pharmaceutical Approaches

The Need to Standardize Our Language Around Dual Antiplatelet Therapy—A Call to Action

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