Efficacy and Safety of Novel Oral P2Y12 Receptor Inhibitors in Patients With ST-Segment Elevation Myocardial Infarction Undergoing PCI: A Systematic Review and Meta-Analysis

Sun, Jianjun; Xiang, Qian; Li, Chao; Wang, Zining; Hu, Kun; Xie, Qiufen; Chen, Yimin

doi:10.1097/fjc.0000000000000459

Cited by 13 publications

(9 citation statements)

References 55 publications

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“…A recent meta-analysis of nine DAPT trials indicated that patients taking ticagrelor had lower rates of adverse events (OR = 0.88; 95% CI, 0.81–0.95) [26]. This is consistent with our finding that T-DAPT patients had less MACE (10.9% vs. 18%, p = 0.003) and reduced all-cause mortality (HR = 0.48; p = 0.001).…”

Section: Discussionsupporting

confidence: 90%

Real-world use of ticagrelor versus clopidogrel in percutaneous coronary intervention-treated ST-elevation myocardial infarction patients: A single-center registry study

Hee

Gibbs

Assad

et al. 2019

Journal of the Saudi Heart Association

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ObjectivesThe primary aim was to investigate the efficacy and safety of dual antiplatelet therapy (DAPT) using ticagrelor (T-DAPT) versus clopidogrel (C-DAPT) in a real-world ST-elevation myocardial infarction (STEMI) population.MethodsWe retrospectively analyzed 655 consecutive patients having primary percutaneous coronary intervention (PCI) for STEMI at Liverpool Hospital, Sydney, Australia (from January 2013 to April 2016). Medical and procedural therapies were at clinician discretion. Patient data were retrieved from hospital records and primary clinicians.ResultsT-DAPT (65%) was used more frequently, and in patients with lower mean CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) score, than C-DAPT (24.6 vs. 32.2; p < 0.0001, respectively). All-cause mortality was 9.0% at 2.7 years follow-up, with fewer deaths for T-DAPT (4.5% vs. 17.2%; p < 0.0001). T-DAPT incurred less BARC (Bleeding Academic Research Consortium) 3–5 major bleeding (5.0% vs. 12.4%; p < 0.0001). Multivariate regression showed that C-DAPT, GRACE (Global Registry of Acute Cardiac Events) score, and renal insufficiency were independently associated with mortality. Intra-aortic balloon pump (IABP) and GRACE score independently predicted BARC 3–5 bleeding. Early DAPT discontinuation (1.7%) and ticagrelor intolerance (7.6%) was rare. Switching DAPT regimen was infrequent (21.7%) and mostly attributed to clinician preference (73.2%). Independent determinants of C-DAPT selection were older age, diabetes, prior PCI, IABP, and higher CRUSADE score.ConclusionTicagrelor was preferred in low bleeding risk patients, which may have contributed to less BARC 3–5 bleeding and lower mortality for T-DAPT. Thus, bleeding mitigation is a clinical priority when selecting DAPT for PCI-treated STEMI patients. Continuation of initial DAPT regimen was typical, but early switching from clopidogrel to ticagrelor shows willingness to optimize DAPT. Patients with very low CRUSADE scores (<21.5) may be appropriate for switching to a potent P2Y12 inhibitor.

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Section: Discussionsupporting

confidence: 90%

Real-world use of ticagrelor versus clopidogrel in percutaneous coronary intervention-treated ST-elevation myocardial infarction patients: A single-center registry study

Hee

Gibbs

Assad

et al. 2019

Journal of the Saudi Heart Association

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“…According to the type of therapy, the risk of gastrointestinal bleeding did not differ between clopidogrel-based DAPT and new antiplatelet-based DAPT group. These results support the conclusions of some studies [16][17][18][19][20][21][22] but differ from others [9][10][11][12][13][14][15]; however, the designs are not comparable. First, most studies have analyzed bleeding as a secondary endpoint and determined the overall risk of bleeding (including, e.g., epistaxis, intracranial, and hematuria) and not specifically gastrointestinal events.…”

Section: Discussionsupporting

confidence: 46%

“…Similarly, in the Study of platelet inhibition and patient outcomes (PLATO trial) [10], compared with the clopidogrel group, the ticagrelor group had a higher risk of major bleeding that was not related to coronary artery bypass graft. However, subsequent studies have yielded contradictory results, with an increased risk of bleeding with prasugrel and ticagrelor in some of them [9][10][11][12][13][14][15], but no differences between clopidogrel and these new compounds in others [16][17][18][19][20][21][22]. The main limitation of acquiring meaningful comparisons among studies and these antiplatelet agents is the variability in bleeding definitions used [23,24].…”

Section: Introductionmentioning

confidence: 99%

No Differences in Gastrointestinal Bleeding Risk among Clopidogrel-, Ticagrelor-, or Prasugrel-Based Dual Antiplatelet Therapy

Laredo

Sostres

García

et al. 2020

JCM

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The risk for gastrointestinal bleeding from dual antiplatelet therapy (DAPT) with new antiplatelets (prasugrel/ticagrelor) compared to clopidogrel is unclear. Aim: To determine the risk and type of major (gastrointestinal bleeding requiring hospitalization) and minor (anemia and iron deficiency) gastrointestinal events with different types of DAPT. Methods: Retrospective observational cohort study of patients who started DAPT after percutaneous coronary intervention. Follow-up was censored after 12 months of DAPT, when a major gastrointestinal event occurred, or when DAPT was discontinued. Results: Among 1,327 patients (54.03% were treated with clopidogrel-based DAPT, 38.13% with ticagrelor-based DAPT, and 7.84% with prasugrel-based DAPT), 29.5% had at least one gastrointestinal event. Patients taking clopidogrel-DAPT were older, with more comorbidities, and higher gastrointestinal risk compared to those taking other DAPT regimens. Adjusted hazard ratios (HRs) showed no between-group differences in the risk for major (clopidogrel vs. new antiplatelets: HR 0.996; 95% confidence interval 0.497–1.996) and minor (HR 0.920; 0.712–1.189) gastrointestinal events. Most patients received proton pump inhibitors while on DAPT (93.3%) and after withdrawal (83.2%). Conclusion: Prasugrel- or ticagrelor-based DAPT was not associated with increased gastrointestinal bleeding risk when compared to clopidogrel-DAPT. New antiplatelets do not necessarily need to be restricted to patients with low gastrointestinal risk.

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“…For patients with non-ST segment elevation acute coronary syndrome, results of a subsequent meta-analysis of 4 RCTs indicated that a novel P2Y 12 antiplatelet was associated with a significantly reduced rate of MACE compared with clopidogrel (risk ratio [RR] = 0.87), but the incidences of major and minor bleeding events were significantly higher (RR = 1.27, 1.20) [14]. For patients with STEMI, results of 3 meta-analyses of RCTs consistently indicated that prasugrel and ticagrelor were more efficacious than clopidogrel for reducing the risk of MACE, although the rates of bleeding events were similar [15][16][17].…”

Section: Discussionmentioning

confidence: 99%

Prasugrel or ticagrelor relative to clopidogrel in triple-antiplatelet treatment combined with glycoprotein IIb/IIIa inhibitor for patients with STEMI undergoing PCI: a meta-analysis

Wang¹,

Zhou²,

Su³

et al. 2020

BMC Cardiovasc Disord

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Background: For patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), the efficacy and safety of novel P2Y 12 antagonists, including prasugrel or ticagrelor, has not been established relative to that of the clopidogrel-based triple-antiplatelet treatments (TAPTs; in combination with glycoprotein IIb/IIIa inhibitor). The present meta-analysis evaluated the efficacy and safety of prasugrel-or ticagrelor-based TAPTs relative to that of clopidogrel TAPTs in patients with STEMI undergoing PCI. Methods: The databases PubMed, Embase, and Cochrane's Library were systematically searched for relevant randomized controlled trials concerning prasugrel or ticagrelor (test) relative to clopidogrel (control). Depending on heterogeneity, studies were pooled with a random effects or a fixed effects model. Outcomes of blood flow after PCI were evaluated, including TIMI (thrombolysis in myocardial infarction), bleeding events, and major adverse cardiovascular events (MACEs). Results: Seven studies comprising 11,874 patients conformed to the inclusion criteria. The pooled results with the fixed effects model indicated that after PCI patients in the prasugrel or ticagrelor groups were as likely as those treated with clopidogrel to achieve TIMI grade 3 flow or experience bleeding events. However, compared with the control, the test groups had significantly less risk of MACE (OR: 0.81, 95% CI: 0.70-0.94, P = 0.004), especially at the 1-year follow-up (OR: 0.79, 95% CI: 0.66-0.95, P = 0.01). Conclusions: A prasugrel-or ticagrelor-based TAPT may reduce the rate of MACEs, without increasing bleeding in STEMI patients undergoing PCI. However, due to the limited RCT studies and variations in study weight, results of this metaanalysis should be confirmed in a large RCT with adequate sample size and follow-up duration.

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Efficacy and Safety of Novel Oral P2Y12 Receptor Inhibitors in Patients With ST-Segment Elevation Myocardial Infarction Undergoing PCI: A Systematic Review and Meta-Analysis

Cited by 13 publications

References 55 publications

Real-world use of ticagrelor versus clopidogrel in percutaneous coronary intervention-treated ST-elevation myocardial infarction patients: A single-center registry study

Real-world use of ticagrelor versus clopidogrel in percutaneous coronary intervention-treated ST-elevation myocardial infarction patients: A single-center registry study

No Differences in Gastrointestinal Bleeding Risk among Clopidogrel-, Ticagrelor-, or Prasugrel-Based Dual Antiplatelet Therapy

Prasugrel or ticagrelor relative to clopidogrel in triple-antiplatelet treatment combined with glycoprotein IIb/IIIa inhibitor for patients with STEMI undergoing PCI: a meta-analysis

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