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Journal of Thrombosis and Thrombolysis Jan 2020The optimal duration dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is subject to debate. A short-duration DAPT (one month to three... (Comparative Study)
Comparative Study Meta-Analysis
Short-term dual antiplatelet therapy (DAPT) followed by P2Y12 monotherapy versus traditional DAPT in patients undergoing percutaneous coronary intervention: meta-analysis and viewpoint.
The optimal duration dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is subject to debate. A short-duration DAPT (one month to three months) followed by P2Y monotherapy instead of standard 6 to 12 months DAPT followed by aspirin monotherapy after PCI has been suggested. We meta-analyzed studies comparing short-term (≤ 3 months) DAPT followed by P2Y monotherapy versus standard DAPT in patients after PCI. In total, 2304 studies were screened at title and abstract level. The primary endpoint was major bleeding. Secondary endpoints included myocardial infarction, stent thrombosis, stroke, and all-cause mortality. Study level data were analyzed. Heterogeneity was assessed using the I statistic. Risk rates (RR) were calculated using a random-effects model (DerSimonian and Laird) for clinical outcomes for each individual study and consecutive pooling. In total, 21970 patients from three studies were analyzed. Between P2Y inhibitor monotherapy versus DAPT, there were similar rates of major bleeding (RR 0.67 95%CI 0.34-1.32; p = 0.25; I 75%), mortality (RR 0.92 95%CI 0.78-1.09; p = 0.33; I 0%) and stroke (RR 0.97 95%CI 0.52 - 0.18; p = 0.92; I 57%). Endpoints assessing thrombotic events showed no statistically significant difference including myocardial infarction (RR 0.99 95%CI 0.85-1.15; p = 0.86; I 0%) and stent thrombosis (RR 1.03 95%CI 0.74-1.44; p = 0.87; I 0%). The experimental treatment with P2Y monotherapy after very short-term DAPT was not superior to standard DAPT. Our meta-analysis adds insight that DAPT might be safely shortened in selected patient strategies. However, DAPT remains the gold standard for antithrombotic treatment after PCI.
Topics: Aspirin; Female; Hemorrhage; Humans; Male; Myocardial Infarction; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Purinergic P2Y Receptor Antagonists; Receptors, Purinergic P2Y12
PubMed: 31686298
DOI: 10.1007/s11239-019-01985-9 -
Thrombosis and Haemostasis May 2024The value of guided therapy (GT) with anti-P2Y12 drugs in percutaneous coronary intervention (PCI) is unclear. Meta-analyses lumped together randomized controlled... (Meta-Analysis)
Meta-Analysis
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 included the effects of switching patients with high on-treatment platelet reactivity (HTPR) to alternative therapies (HTPR-Therapy). We performed three 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 1, 2022. Two reviewers extracted the data. Risk ratios (RRs) (95% confidence intervals) were calculated. Primary outcomes were major bleedings (MBs) and major adverse cardiovascular events (MACE).
RESULTS
In seven genotype-GT RCTs, RRs were: MB, 1.06 (0.73-1.54; = 0.76); MACE, 0.65 (0.47-0.91; = 0.01), but significant risk reduction was observed in RCTs performed in China (0.30, 0.16-0.54; < 0.0001) and not elsewhere (0.75, 0.48-1.18; = 0.21). In six PFT-GT RCTs, RRs were: MB, 0.91 (0.64-1.28, = 0.58); MACE, 0.82 (0.56-1.19; = 0.30): 0.62 (0.42-0.93; = 0.02) in China, 1.08 (0.82-1.41; = 0.53) elsewhere. In eight HTPR-Therapy RCTs, RRs were: MB, 0.71 (0.41-1.23; = 0.22); MACE, 0.57 (0.44-0.75; < 0.0001): 0.56 (0.43-0.74, < 0.0001) in China, 0.58 (0.27-1.23, = 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.
Topics: Percutaneous Coronary Intervention; Humans; Randomized Controlled Trials as Topic; Purinergic P2Y Receptor Antagonists; Platelet Function Tests; Platelet Aggregation Inhibitors; Hemorrhage; Blood Platelets; Treatment Outcome; Receptors, Purinergic P2Y12; Coronary Artery Disease; Genotype
PubMed: 37549688
DOI: 10.1055/a-2149-4344