Key result
In elderly patients with ACS, potent P2Y12 inhibitors had a similar risk of MACE compared with clopidogrel (HR 0.94; 95% CI 0.85-1.06; P=0.31), but reduced cardiovascular death and increased major bleeding.
Why the study?
Elderly patients with ACS have an increased bleeding risk, and whether the benefit-risk ratio of potent P2Y12 inhibitors remains favorable in this population is unknown.
Meta-Analysis (n=10,792)
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“An important thing that we address in this review article is the concept that one size does not fit all with regard to our elderly patients. Obviously, the elderly patients who qualify to be enrolled in clinical trials may not be the same as those that we see in real-world clinical practice. Additionally, when we look at the elderly overall as a cohort, there remain a lot of unanswered questions simply because in the vast majority of trials that we conduct, the elderly only represent a subgroup.”
May support potent P2Y12 inhibitors in elderly ACS; leaves open confirmation by dedicated RCTs.
BACKGROUND Potent P2Y12 inhibitors reduce cardiovascular events but increase bleeding in patients presenting with acute coronary syndrome (ACS). Elderly patients are at increased risk of bleeding and whether the benefit-risk ratio of potent P2Y12 inhibitors remains favorable is not known. OBJECTIVES To investigate the efficacy and safety of potent P2Y12 inhibitors versus clopidogrel in elderly patients with ACS. METHODS PUBMED and EMBASE were searched through July 2020 for randomized control trials (RCTs) or subgroup analyses of RCTs investigating potent P2Y12 inhibitors (prasugrel or ticagrelor) or clopidogrel in elderly (age ≥ 65 years) patients with ACS. The primary outcome was major adverse cardiovascular events (MACE). RESULTS Our search identified 9 RCTs with a total of 10,792 elderly patients. When compared with clopidogrel, potent P2Y12 inhibitors had similar risk of MACE (hazard ratio (HR): 0.94; 95%; confidence interval (CI) [0.85-1.06], P=0.31, I2=9%), all-cause mortality (HR: 0.89; 95% CI [0.74-1.07], P=0.22, I2=29%), reduced the risk of cardiovascular death (HR: 0.82; 95% CI [0.68-0.98], P=0.03, I2=16%) but increased the risk of major bleeding (HR: 1.27; 95% CI [1.04-1.56], P=0.02, I2=0%). In a subgroup analysis, ticagrelor reduced all-cause mortality (HR: 0.73; 95% CI [0.55-0.98]) and cardiovascular death (HR: 0.70; 95% CI [0.54-0.90]) compared with clopidogrel. CONCLUSIONS Among elderly patients with ACS, potent P2Y12 inhibitors reduce cardiovascular death but increase bleeding with no difference in MACE or all-cause death when compared with clopidogrel. Further RCTs are needed to refine P2Y12 inhibitor selection for elderly patients with ACS.
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Fujisaki et al. (2021) conducted a meta-analysis in Acute coronary syndrome (n=10,792). Potent P2Y12 inhibitors (prasugrel or ticagrelor) vs. Clopidogrel was evaluated on Major adverse cardiovascular events (MACE) (HR 0.94, 95% CI 0.85-1.06, p=0.31). In elderly patients with ACS, potent P2Y12 inhibitors had a similar risk of MACE compared with clopidogrel (HR 0.94; 95% CI 0.85-1.06; P=0.31), but reduced cardiovascular death and increased major bleeding.
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