Key result
Ticagrelor carries ~23% higher MACE risk versus prasugrel, while clopidogrel de-escalation reduces major bleeding.
Why the study?
Balancing the effects of DAPT in the era of potent P2Y12 inhibitors remains a clinical challenge in the management of ACS.
Does ticagrelor (vs prasugrel) or P2Y12 inhibitor de-escalation (vs continuation) improve cardiovascular and bleeding outcomes in ACS patients undergoing PCI?
Meta-Analysis (n=8,914)
Does ticagrelor (vs prasugrel) or P2Y12 inhibitor de-escalation (vs continuation) improve cardiovascular and bleeding outcomes in ACS patients undergoing PCI?
In ACS patients undergoing PCI, prasugrel may be superior to ticagrelor for MACE reduction, and de-escalating to clopidogrel after 1 month reduces major bleeding without increasing thrombotic risk.
Prasugrel may reduce MACE versus ticagrelor after ACS PCI; challenges ticagrelor preference and supports clopidogrel de-escalation in trials.
Abstract Background Balancing the effects of dual antiplatelet therapy (DAPT) in the era of potent purinergic receptor type Y, subtype 12 (P2Y₁₂) inhibitors remains a challenge in the management of acute coronary syndrome (ACS). Methods We conducted a systematic review and meta-analysis following a 2-stage process consisting of searching for systematic reviews published between 2019 and November 2022. We included randomized controlled trials (RCTs) of ACS patients treated with percutaneous coronary intervention comparing (i) ticagrelor- vs prasugrel-based DAPT and (ii) P2Y₁₂ inhibitor de-escalation strategies. Outcomes of interest were major adverse cardiovascular events (MACE), all-cause death, stent thrombosis, and major bleeding. We estimated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model. Results Eight RCTs (n = 5571) compared ticagrelor to prasugrel. Ticagrelor was associated with an increased risk of MACE compared to prasugrel (RR 1.23, 95% CI 1.01-1.49, moderate certainty), without significant differences in death, stent thrombosis, or major bleeding. In 2 RCTs (n = 3343) comparing clopidogrel-based DAPT de-escalation after 1 month to potent P2Y₁₂ inhibitor–based DAPT continuation, clopidogrel de-escalation did not significantly alter the incidence of MACE, death, or stent thrombosis, but reduced that of major bleeding (RR 0.51, 95% CI 0.28-0.92, high certainty). The effect of prasugrel dose de-escalation was inconclusive for all outcomes based on one trial. Conclusions Ticagrelor was associated with an increase in MACE compared with prasugrel, based on low-certainty evidence, whereas de-escalation to clopidogrel after 1 month of potent P2Y₁₂ inhibitor was associated with a decrease in incidence of major bleeding without increasing thrombotic outcomes in ACS patients post-percutaneous coronary intervention.
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Boivin‐Proulx et al. (2023) conducted a meta-analysis in Acute coronary syndrome (ACS) (n=8,914). Ticagrelor vs. Prasugrel was evaluated on Major adverse cardiovascular events (MACE) (RR 1.23, 95% CI 1.01-1.49). Ticagrelor was associated with an increased risk of MACE compared to prasugrel (RR 1.23; 95% CI 1.01-1.49), while de-escalation to clopidogrel reduced major bleeding (RR 0.51; 95% CI 0.28-0.92).
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