Key result
De-escalation from prasugrel or ticagrelor to clopidogrel significantly reduced the incidence of net adverse clinical events (8.2% vs 12.2%; RR 0.67) in patients with ACS undergoing PCI.
Why the study?
There is no definite conclusion on the strategy of switching from potent P2Y 12 inhibitors to clopidogrel after percutaneous coronary intervention in patients with acute coronary syndromes.
Does de-escalation from prasugrel/ticagrelor to clopidogrel reduce net adverse clinical events and bleeding in patients with ACS undergoing percutaneous coronary intervention?
Meta-Analysis (n=7,627)
Does de-escalation from prasugrel/ticagrelor to clopidogrel reduce net adverse clinical events and bleeding in patients with ACS undergoing percutaneous coronary intervention?
Relative Risk: 0.67 (95% CI 0.58–0.78)
Absolute Event Rate: 8.2% vs 12.2%
p-value: p=<0.00001
De-escalation of antiplatelet therapy from prasugrel or ticagrelor to clopidogrel in ACS patients undergoing PCI significantly reduces net adverse clinical events and bleeding without increasing ischemic risk.
De-escalation to clopidogrel reduces bleeding without increasing ischemic events in ACS post-PCI; confirms safety in pooled RCTs and supports individualized DAPT.
Purpose: This meta-analysis was conducted to study the efficacy and safety of switching from potent P2Y 12 inhibitors to clopidogrel, because there is no definite conclusion on the strategy. Method: We conducted a systematic review and meta-analysis of patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention, and compared the efficacy and safety of de-escalation or not of anti-platelet therapy. The relevant randomized controlled trials were included by searching several databases. Net adverse clinical events were identified as the composite endpoint, which was defined as a composite of cardiovascular death, myocardial infarction, revascularization, stroke and bleeding at 12 months after ACS. The efficacy endpoints were cardiovascular death, myocardial infarction, revascularization, stroke, all-cause death and stent thrombosis. Bleeding was designed as the safety endpoint. The relative risk (RR) and 95% confidence intervals (CI) of endpoint events were calculated by the fixed effects model. Result: Six randomized controlled trials with 7627 patients met inclusion criteria. There were significant differences in the risk of net adverse clinical events (RR 0.67, CI 0.58–0.78, P < 0.00001), and bleeding endpoint (0.61, 0.52–0.71, P < 0.00001) between the two groups. However, there were no significant differences in the risk of all efficacy endpoints. Conclusions: The strategy of de-escalation from prasugrel/ticagrelor to clopidogrel can reduce the incidence of net adverse clinical events and bleeding events in patients with ACS undergoing percutaneous coronary intervention (Registered by PROSPERO at July 04 2021, ID 265782).
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Bai et al. (2021) conducted a meta-analysis in Acute Coronary Syndromes (ACS) undergoing percutaneous coronary intervention (PCI) (n=7,627). De-escalation of anti-platelet therapy (switching from prasugrel/ticagrelor to clopidogrel) vs. Non-de-escalation (maintaining original potent P2Y12 inhibitors) was evaluated on Net adverse clinical events (composite of cardiovascular death, myocardial infarction, revascularization, stroke and bleeding at 12 months) (RR 0.67, 95% CI 0.58-0.78, p=<0.00001). De-escalation from prasugrel or ticagrelor to clopidogrel significantly reduced the incidence of net adverse clinical events (8.2% vs 12.2%; RR 0.67) in patients with ACS undergoing PCI.
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