Key result
12-month prasugrel plus aspirin cuts MI ~29% versus clopidogrel, with similar MACE and major bleeding.
Why the study?
The choice of duration and kind of DAPT offering the best balance between ischemic and bleeding risk in ACS patients treated with PCI remains unknown.
Do different dual antiplatelet therapy (DAPT) regimens and durations improve outcomes in acute coronary syndrome patients undergoing PCI?
Meta-Analysis (n=46,145)
Do different dual antiplatelet therapy (DAPT) regimens and durations improve outcomes in acute coronary syndrome patients undergoing PCI?
In ACS patients undergoing PCI, different DAPT strategies yield similar risks of MACE and major bleeding, but prasugrel plus aspirin for 12 months is the most effective strategy for reducing stent thrombosis and MI.
Supports prasugrel-aspirin DAPT for 12 months in ACS-PCI to reduce MI; confirms comparable MACE and bleeding across regimens.
INTRODUCTION: For acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI), the choice of the duration and kind of dual antiplatelet therapy (DAPT) offering the most accurate balance between ischemic and bleeding risk remains unknown. EVIDENCE ACQUISITION: A network meta-analysis was performed including all Randomized Controlled Trials (RCTs) comparing different DAPT regimens and duration in ACS patients undergoing PCI. Trial-defined MACE and major bleedings were the primary endpoints. Stroke, stent thrombosis (ST), all-cause and cardiovascular death, myocardial infarction (MI) represented secondary endpoints. EVIDENCE SYNTHESIS: 13 RCTs encompassing 46145 patients were included. Mean age was 62 (61-64) years old, 42% being admitted with STEMI, 33% with NSTEMI and 25% with UA. The competitive arms were: clopidogrel and aspirin for 12 months (6 arms/18183 patients), clopidogrel and aspirin for 6 months (4/3329), clopidogrel and aspirin >12 months (3/2238), ticagrelor and aspirin for 12 months (6/12942) and prasugrel and aspirin for 12 months (3/9453). Trial-defined MACE and major bleedings, stroke and death were similar among the different arms. DAPT with prasugrel and aspirin for 12 months reduced MI compared to aspirin and clopidogrel for 12 months (OR 0.71, 95% CI: 0.54.0.94) and reduced the risk of ST compared to ticagrelor (OR 0.66, 95% CI: 0.49-0.90). Both prasugrel and ticagrelor reduced ST as compared to clopidogrel and aspirin for 12 months. CONCLUSIONS: Different DAPT strategies yield similar risk of MACE, major bleeding, death and stroke in ACS patients. Prasugrel and aspirin for 12 months proved to be the most effective strategy regarding ST and MI.
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D’Ascenzo et al. (2022) conducted a meta-analysis in Acute coronary syndrome (ACS) (n=46,145). Prasugrel and aspirin vs. Clopidogrel and aspirin, ticagrelor and aspirin, and varying durations was evaluated on Trial-defined MACE and major bleedings. Prasugrel and aspirin for 12 months reduced myocardial infarction compared to clopidogrel and aspirin for 12 months (OR 0.71; 95% CI 0.54-0.94), while MACE and major bleeding were similar across arms.