Does individualized guided selection of antiplatelet therapy improve outcomes after percutaneous coronary intervention? A systematic review and meta-analysis

Yamani, Naser; Unzek, Samuel; Mankani, Muhammad Hasnain; Almas, Talal; Musheer, Adeena; Qamar, Humera; Farooq, Shausha; Shahnawaz, Waqas; Fatima, Kaneez; Figueredo, Vincent M.; Mookadam, Farouk

doi:10.1016/j.amsu.2022.103964

Cited by 6 publications

(4 citation statements)

References 34 publications

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“…Meta-analyses that considered RCTs only, or analyzed the results of RCTs separately from those of observational studies, lumped together RCTs with heterogeneous designs, testing genotype-GT or PFT-GT, 30 PFT-GT or HTPR-Therapy, 30 genotype-GT, PFT-GT or HTPR-Therapy. 31 Therefore, these meta-analyses are unable to provide the necessary information of what GT strategy, if any, improves the clinical benefit of anti-P2Y12 therapy. Two meta-analyses included genotype-GT RCTs only 32 33 ; no meta-analysis analyzed PFT-GT RCTs only.…”

Section: Introductionmentioning

confidence: 99%

Guided Anti-P2Y12 Therapy in Patients Undergoing PCI: Three Systematic Reviews with Meta-analyses of Randomized Controlled Trials with Homogeneous Design

Birocchi,

Rocchetti,

Minardi

et al. 2023

Thromb Haemost

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Background: The value of guided therapy (GT) with anti-P2Y12 drugs in percutaneous coronary intervention (PCI) is unclear. Meta-analyses lumped together randomized controlled trials (RCTs) with heterogeneous designs, comparing either genotype-GT or platelet function test (PFT)-GT with unguided therapy. Some meta-analysis also included RCTs that did not explore GT, but the effects of switching patients with high on-treatment platelet reactivity (HTPR) to alternative therapies (HTPR-Therapy). We performed 3 distinct systematic reviews/meta-analyses, each exploring only RCTs with homogeneous design. Methods. MEDLINE, Embase and Central databases were searched for RCTs testing genotype-GT, PFT-GT or HTPR-Therapy in PCI-treated patients, through October 1st 2022. Two reviewers extracted the data. Risk ratios (RR) (95% confidence intervals) were calculated. Primary outcomes were major bleedings (MB) and major adverse cardiovascular events (MACE). Results: In 7 genotype-GT RCTs, RR were: MB, 1.06 (0.73–1.54; p=0.76); MACE, 0.65 (0.47–0.91); p=0.01), but significant risk reduction was observed in RCTs performed in China (0.30, 0.16-0.54; p<0.0001) and not elsewhere (0.75, 0.48-1.18; p=0.21). In 6 PFT-GT RCTs, RR were: MB, 0.91 (0.64-1.28, p=0.58); MACE, 0.82 (0.56 –1.19; p=0.30): 0.62 (0.42-0.93; p=0.02) in China, 1.08 (0.82-1.41; p=0.53) elsewhere. In 8 HTPR-Therapy RCTs, RR were: MB, 0.71 (0.41-1.23; p=0.22); MACE, 0.57 (0.44–0.75; p<0.0001): 0.56 (0.43-0.74, p<0.0001) in China, 0.58 (0.27-1.23, p=0.16) elsewhere. Conclusion: No GT strategy affected MB. Overall, genotype-GT but not PFT-GT reduced MACE. However, genotype-GT and PFT-GT reduced MACE in China, but not elsewhere. PFT-GT performed poorly compared to HTPR-Therapy, likely due to inaccurate identification of HTPR patients by PFT.

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Section: Introductionmentioning

confidence: 99%

Guided Anti-P2Y12 Therapy in Patients Undergoing PCI: Three Systematic Reviews with Meta-analyses of Randomized Controlled Trials with Homogeneous Design

Birocchi,

Rocchetti,

Minardi

et al. 2023

Thromb Haemost

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“…Despite these uncertainties, the importance of maintaining the balance between thrombotic and bleeding risk cannot be overstated in reducing the incidence of antiplatelet resistance [10]. Evidence has linked antiplatelet resistance to poor clinical outcomes [11,12]. Platelet function testing is a widely used method to evaluate the effects of antiplatelet drugs [13,14], which has revealed that one-third of patients exhibit aspirin and clopidogrel resistance [15].…”

Section: Introductionmentioning

confidence: 99%

Role and Clinical Significance of Thromboelastography-Guided Individualized Antiplatelet Therapy in Non-cardiogenic Ischemic Stroke: A Retrospective Cohort Study

Zhang

Wang

2023

Preprint

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This study examined the impact of individualized antiplatelet (IA) therapy guided by Thromboelastography (TEG) in non-cardiogenic ischemic stroke patients. The patients were divided into an IA group and a control group receiving conventional treatment. A one-year follow-up tracked mortality, bleeding events, and ischemic events. 715 patients were initially enrolled, with 684 meeting the inclusion criteria (487 in IA group, 197 in control group). IA therapy significantly reduced the composite rate of death, bleeding, or ischemic events compared to conventional therapy (7.39% vs. 15.74%, P = 0.001). The IA group showed a lower incidence of combined bleeding or ischemic events (6.98% vs. 15.32%, P = 0.001). Furthermore, the IA group had lower rates of ischemic stroke (2.46% vs. 5.58%, P = 0.04) and myocardial infarction (3.08% vs. 6.6%, P = 0.035) compared to the control group. Cox regression analysis revealed that age (hazard ratio, 1.043; 95% CI, 1.01-1.078, P = 0.011) and coronary artery disease (hazard ratio, 1.902; 95% CI, 1.147-3.153, P = 0.013) were associated with increased risk of adverse events compared to the control group. A therapy guided by platelet function testing can effectively reduce adverse events, particularly the risk of ischemic events, in the clinical prognosis of ischemic stroke. However, Caution is needed in IA therapy for elderly and coronary heart disease patients due to potential risks. Further large-scale experiments are required to validate and optimize personalized antiplatelet therapy in this population. Trial Registration clinicaltrials.gov Identifier: NCT 03471169

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“…Some meta-analyses lumped together RCTs, non-randomized intervention studies and observational studies (43)(44)(45)(46)(47). Meta-analyses that considered RCTs only, or analyzed the results of RCTs separately from those of observational studies, lumped together RCTs with heterogeneous designs, testing genotype-GT or PFT-GT (46), PFT-GT or HTPR-Therapy (48), genotype-GT, PFT-GT or HTPR-Therapy (49). Therefore, these meta-analyses are unable to provide the necessary information of what GT strategy, if any, improves the clinical benefit of anti-P2Y12 therapy.…”

Section: Introductionmentioning

confidence: 99%

Guided antiplatelet therapy with P2Y12 antagonists in patients undergoing percutaneous coronary intervention: 3 systematic reviews with meta-analyses of randomized controlled trials with homogeneous design

Birocchi

Rocchetti

Minardi

et al. 2023

Preprint

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Background: Conflicting results were reported by randomized controlled trials (RCTs) exploring guided therapy (GT) with anti-P2Y12 drugs in patients undergoing percutaneous coronary intervention (PCI). Meta-analyses of RCTs failed to clearly identify what GT strategy, if any, is effective, because they lumped together RCTs with heterogeneous designs, comparing either genotype-GT or platelet function test (PFT)-GT with unguided standard therapy. Some meta-analysis also included RCTs that did not actually explore GT, but tested the effects of switching patients with high on-treatment platelet reactivity (HTPR) to alternative therapies (HTPR-Therapy), rather than comparing GT with unguided standard therapy. We performed 3 distinct systematic reviews with meta-analyses, each exploring only RCTs with homogeneous design. Methods. MEDLINE, Embase and Central databases were searched for RCTs testing genotype-GT, PFT-GT or HTPR-Therapy in PCI-treated patients, through October 1st 2022. Two reviewers extracted the data. Risk ratios (RR) (95% confidence intervals) were calculated. Primary outcomes were major bleedings (MB) and major adverse cardiovascular events (MACE). Results: In 7 genotype-GT RCTs, RR were: MB, 1.06 (0.73?1.54; p=0.76); MACE, 0.64 (0.45?0.91; p=0.01), but significant risk reduction was observed only in RCTs performed in China (0.30, 0.16-0.54; p<0.0001) and not elsewhere (0.74, 0.46-1.18; p=0.21). In 6 PFT-GT RCTs, RR were: MB, 0.91 (0.64-1.28, p=0.58); MACE, 0.82 (0.5 ?1.19; p=0.30): 0.62 (0.42-0.93; p=0.02) in China, 1.08 (0.82-1.41; p=0.53) elsewhere. In 8 HTPR-Therapy RCTs, RR were: MB, 0.71 (0.41-1.23; p=0.22); MACE, 0.57 (0.44?0.75; p<0.0001): 0.56 (0.43-0.74, p<0.0001) in China, 0.58 (0.27-1.23, p=0.16) elsewhere. Conclusion: No GT strategy affected MB. Genotype-GT but not PFT-GT reduced MACE; subgroup analysis revealed that genotype-GT and PFT-GT reduced MACE in China, but not elsewhere. PFT-GT (which analyzed both patients with and without HTPR) performed poorly compared to HTPR-Therapy (which analyzed HTPR patients only), likely due to inaccurate identification of HTPR patients by PFTs. PROSPERO registration: CRD42022362739.

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Does individualized guided selection of antiplatelet therapy improve outcomes after percutaneous coronary intervention? A systematic review and meta-analysis

Cited by 6 publications

References 34 publications

Guided Anti-P2Y12 Therapy in Patients Undergoing PCI: Three Systematic Reviews with Meta-analyses of Randomized Controlled Trials with Homogeneous Design

Guided Anti-P2Y12 Therapy in Patients Undergoing PCI: Three Systematic Reviews with Meta-analyses of Randomized Controlled Trials with Homogeneous Design

Role and Clinical Significance of Thromboelastography-Guided Individualized Antiplatelet Therapy in Non-cardiogenic Ischemic Stroke: A Retrospective Cohort Study

Guided antiplatelet therapy with P2Y12 antagonists in patients undergoing percutaneous coronary intervention: 3 systematic reviews with meta-analyses of randomized controlled trials with homogeneous design

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