What question did this study set out to answer?

To evaluate the efficacy and safety of individualized, intensified dual antiplatelet therapy guided by platelet function testing in patients with high on-treatment platelet reactivity undergoing percutaneous coronary intervention.

June 15, 2017BMC Cardiovascular DisordersOpen Access

Individualized dual antiplatelet therapy based on platelet function testing in patients undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials

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Why the study?

Does individualized intensified dual antiplatelet therapy based on platelet function testing reduce major adverse cardiovascular events in patients undergoing percutaneous coronary intervention?

Key Points

To evaluate the efficacy and safety of individualized, intensified dual antiplatelet therapy guided by platelet function testing in patients with high on-treatment platelet reactivity undergoing percutaneous coronary intervention.
Meta-analysis of 13 randomized controlled trials published between 2005 and 2016 involving 7,290 patients undergoing percutaneous coronary intervention.
Compared intensified antiplatelet therapy with a receptor inhibitor against standard maintenance-dose clopidogrel based on platelet function testing.
Intensified therapy significantly reduced major adverse cardiovascular events (RR: 0.55, 95% CI: 0.36–0.84, p = 0.005) and cardiovascular death (RR: 0.60, 95% CI: 0.38–0.96, p = 0.03) compared to standard clopidogrel.
The tailored protocol significantly decreased stent thrombosis (RR: 0.58, 95% CI: 0.36–0.93, p = 0.02) and target vessel revascularization (RR: 0.33, 95% CI: 0.14–0.76, p = 0.009), with no significant difference in bleeding events.

Structured PICO

Does individualized intensified dual antiplatelet therapy based on platelet function testing reduce major adverse cardiovascular events in patients undergoing percutaneous coronary intervention?

Population

13 randomized controlled trials comprising 7,290 patients undergoing percutaneous coronary intervention (PCI) with high on-treatment platelet reactivity (HPR) based on platelet function testing.

Intervention

Individualized intensified dual antiplatelet therapy (DAPT) with P2Y12 receptor inhibitors (repeated loading dose of clopidogrel, increased maintenance dose of clopidogrel, or switching to prasugrel) guided by platelet function testing.

Comparator

Standard maintenance dose of clopidogrel.

Outcome

Major adverse cardiovascular events (MACE), primarily defined as a composite of cardiovascular death, myocardial infarction, and definite/probable stent thrombosis.composite

Individualized intensified antiplatelet therapy based on platelet reactivity testing significantly reduces cardiovascular events in PCI patients with high on-treatment platelet reactivity without increasing bleeding risk.

Limitations

No general agreement on standard definition of platelet resistance, with different definitions used across studies.
Different strategies used to overcome HPR, resulting in varying extents of platelet inhibition.
Different risk profiles of patients included across the studies.
Patients with and without high on-treatment reactivity were mixed in the platelet function monitoring group in some studies (e.g., ARCTIC and ANTARCTIC trials).

Implication

Supports phenotype-guided DAPT escalation to reduce MACE in PCI patients with.

Abstract

BACKGROUND: High on-treatment platelet reactivity (HPR) represents a strong risk factor for thrombotic events after PCI. We aim to evaluate the efficacy and safety of individualizing intensified dual antiplatelet therapy (DAPT) in PCI-treated patients with HPR based on platelet function testing (PFT). METHODS: receptor inhibitor comparing with standard maintenance dose of clopidogrel on the basis of platelet function testing. Clinical endpoints were assessed. RESULTS: From 2005 to 2016, thirteen clinical studies comprising 7290 patients were included for analysis. Compared with standard antiplatelet therapy with clopidogrel, the intensified protocol based on platelet function testing was associated with a significant reduction in major adverse cardiovascular events (RR:0.55, 95% CI: 0.36-0.84, p = 0.005), cardiovascular death (RR:0.60, 95% CI: 0.38-0.96, p = 0.03), stent thrombosis (RR:0.58, 95% CI: 0.36-0.93, p = 0.02) and target vessel revascularization (RR:0.33, 95% CI: 0.14-0.76, p = 0.009). No significant difference was found in the rate of bleeding events between intensified and standard protocol. CONCLUSIONS: Compared with standard clopidogrel therapy, individualized intensified antiplatelet therapy on the basis of platelet reactivity testing reduces the incidence of cardiovascular events in patient undergoing PCI, without increasing the risk of bleeding.