Key result
Upfront unguided antiplatelet de-escalation increases MACE ~16% in non-East Asians, unlike other safe bleeding reduction strategies.
Why the study?
The generalizability of bleeding reduction antiplatelet regimens in ACS may be influenced by ethnicity, given differing ischaemic-bleeding risk profiles between East Asian and non-East Asian patients.
Do bleeding reduction antiplatelet treatment regimens improve bleeding outcomes without increasing MACE compared to standard 12-month DAPT in patients with ACS undergoing PCI, and does ethnicity influence this effect?
Meta-Analysis
Do bleeding reduction antiplatelet treatment regimens improve bleeding outcomes without increasing MACE compared to standard 12-month DAPT in patients with ACS undergoing PCI, and does ethnicity influence this effect?
Effect estimate: RR 1.16 (95% CI 1.09-1.24)
Most bleeding reduction antiplatelet strategies reduce bleeding without increasing ischemic risk in ACS patients undergoing PCI, though efficacy and safety profiles vary by ethnicity.
Caution against upfront unguided de-escalation in non-East Asians; extends meta-analytic evidence on ethnicity-specific antiplatelet safety.
AIMS: Randomized controlled trials (RCTs) testing bleeding reduction strategies using antiplatelet treatment regimens (BRATs) in acute coronary syndromes (ACS) have shown promising results, but the generalizability of these findings may be significantly influenced by the ethnicity of the patients enrolled, given that East Asian (EA) patients show different ischaemic-bleeding risk profile compared to non-EA patients. METHODS AND RESULTS: RCTs comparing a BRAT vs. standard 12-month dual antiplatelet therapy (DAPT) in patients with ACS undergoing percutaneous coronary intervention (PCI) were selected. The primary efficacy endpoint was major adverse cardiovascular events (MACE) as defined in each trial and the primary safety endpoint was minor or major bleeding. Twenty-six RCTs testing seven different BRATs were included. The only strategy associated with a trade-off in MACE was 'upfront unguided de-escalation' in the subgroup of non-EAs (risk ratio 1.16, 95% confidence interval 1.09-1.24). All but aspirin monotherapy-based strategies (i.e. 'short and very short DAPT followed by aspirin') were associated with reduced bleeding compared with standard DAPT in both EA and non-EA patients. There were no significant differences between subgroups, but the lack of RCTs in some of the included strategies and the difference in the certainty of evidence between EA and non-EA patients revealed that the evidence in support of different BRATs in ACS undergoing PCI is influenced by ethnicity. Moreover, absolute risk reduction estimation revealed that some BRATs might be more effective than others in reducing bleeding according to ethnicity. CONCLUSION: The majority of BRATs are associated with reduced bleeding without any trade-off in hard ischaemic endpoints regardless of ethnicity. However, the supporting evidence and relative safety profiles of different BRATs might be significantly affected by ethnicity, which should be taken into account in clinical practice. STUDY REGISTRATION: This study is registered in PROSPERO (CRD42023416710).
No takes yet. Share an insight, caveat, or question.
Galli et al. (2023) conducted a meta-analysis in Acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI). Bleeding reduction strategies using antiplatelet treatment regimens (BRATs) vs. Standard 12-month dual antiplatelet therapy (DAPT) was evaluated on Major adverse cardiovascular events (MACE) and minor or major bleeding (RR 1.16, 95% CI 1.09-1.24). Most antiplatelet bleeding reduction strategies reduced bleeding without increasing MACE across ethnicities, except upfront unguided de-escalation in non-East Asians (MACE RR 1.16; 95% CI 1.09-1.24).
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: