Key result
P2Y12 inhibitor monotherapy significantly reduced major bleeding (RR 0.65; 95% CI 0.46-0.91), whereas de-escalation did not significantly reduce major bleeding (RR 0.84; 95% CI 0.57-1.22).
Why the study?
Multiple trials tested DAPT abatement schemes including P2Y12 inhibitor de-escalation or monotherapy after PCI in ACS, but yielded heterogeneous results.
Do DAPT abatement strategies (de-escalation or monotherapy) reduce MACE and bleeding in ACS patients treated with PCI?
Meta-Analysis
Do DAPT abatement strategies (de-escalation or monotherapy) reduce MACE and bleeding in ACS patients treated with PCI?
Relative Risk: 0.65 (95% CI 0.46–0.91)
In PCI-treated ACS patients, DAPT abatement via P2Y12 inhibitor monotherapy significantly reduces major bleeding, while both monotherapy and de-escalation appear to be viable alternatives for reducing overall bleeding.
Favors P2Y12 monotherapy over de-escalation for major bleeding reduction post-PCI in ACS; extends evidence distinguishing DAPT abatement strategies.
Introduction: Dual antiplatelet therapy (DAPT) including prasugrel or ticagrelor is recommended in patients with acute coronary syndromes (ACS) treated with coronary intervention (PCI). Acknowledging the importance of bleeding, multiple trials tested abatement schemes including uniform or guided de-escalation from the potent P2Y12 inhibitor (P2Y12-De) or P2Y12 inhibitor monotherapy (P2Y12-Mo) with heterogeneous results. We aimed to perform a systematic review and network meta-analysis of the impact of DAPT abatement strategies in patients with PCI. Methods: Electronic databases were searched for relevant randomized clinical studies evaluating clinical outcomes of patients after PCI. The rate of adverse events was evaluated using a frequentist network metanalysis. The random-effects model was used to combine risk estimates across trials and risk ratio (RR) with 95% confidence intervals (95% CIs) served as summary statistics. The primary endpoints of interest were the rate of major cardiac adverse events (MACE, defined as the composite of cardiovascular mortality, myocardial infarction and stroke) and bleeding. Results: < 0.05 both). A 35% risk reduction of major bleeding was seen with monotherapy (RR: 0.65 [0.46, 0.91],) contrasting the de-escalation trials where this effect was not significant (RR: 0.84 [0.57, 1.22]). All bleeding and minor bleeding events were reduced with both strategies. Indirect P2Y12-Mo versus P2Y12-De comparisons exhibited them as similar alternatives without significant differences. Conclusion: Our analysis suggests that both P2Y12-De and P2Y12-Mo reduce ischemic events and bleeding among PCI-treated ACS patients. Ischemic benefit was more expressed with P2Y12-De, however, reduction of major bleeding was only significant with P2Y12-Mo strategy. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021258502, identifier CRD42021258502.
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Abdallaoui et al. (2023) conducted a meta-analysis in Acute coronary syndromes (ACS) treated with PCI. P2Y12 inhibitor monotherapy or de-escalation vs. Standard dual antiplatelet therapy was evaluated on Major bleeding (RR 0.65, 95% CI 0.46-0.91). P2Y12 inhibitor monotherapy significantly reduced major bleeding (RR 0.65; 95% CI 0.46-0.91), whereas de-escalation did not significantly reduce major bleeding (RR 0.84; 95% CI 0.57-1.22).
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