Key result
P2Y12 de-escalation to clopidogrel yields no difference in MACE or major bleeding versus standard therapy.
Why the study?
Switching from a potent P2Y12 blocker to clopidogrel is not uncommon in patients undergoing PCI, but the efficacy and safety of this de-escalation strategy remained to be comprehensively investigated.
Does de-escalation therapy (switching from a potent P2Y12 blocker to clopidogrel) reduce major adverse cardiovascular events and major bleeding in patients undergoing percutaneous coronary intervention compared to standard potent antiplatelet therapy?
Meta-Analysis (n=17,896)
Does de-escalation therapy (switching from a potent P2Y12 blocker to clopidogrel) reduce major adverse cardiovascular events and major bleeding in patients undergoing percutaneous coronary intervention compared to standard potent antiplatelet therapy?
Odds Ratio: 0.91 (95% CI 0.73–1.14)
p-value: p=0.43
De-escalation from potent P2Y12 inhibitors to clopidogrel in PCI patients appears to have similar efficacy and safety compared to standard therapy, with no significant differences in ischemic or bleeding events.
Supports de-escalation as equivalent strategy in PCI; confirms similar MACE and bleeding risk versus standard potent therapy in meta-analysis.
Switching from a potent P2Y12 blocker to clopidogrel is not uncommon for antiplatelet therapy in patients undergoing percutaneous coronary intervention. This meta-analysis aimed to investigate the efficacy and safety of this de-escalation strategy. Medical literature databases were searched for analysis comparing continued potent antiplatelet therapy and switching to clopidogrel with no language restrictions from inception to 07/May/2018. The primary endpoints of major adverse cardiovascular events (MACE) and major bleeding together with additional efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. A total of 17 896 patients in 13 studies were eligible for analysis, while 17 579 (98.2%) patients presented as acute coronary syndrome and 4105 (23%) patients received the de-escalation therapy. Incidence of MACE was virtually identical in both de-escalation and standard potent antiplatelet therapy groups (odds ratio 0.91, 95% CI 0.73–1.14; P = 0.43). Insignificant difference was also observed in major bleeding (0.99, 0.62–1.60; P = 0.97), all-cause death (0.95, 0.61–1.46; P = 0.81), cardiovascular death (0.66, 0.31–1.42; P = 0.29), myocardial infarction (1.12, 0.80–1.58; P = 0.51), stent thrombosis (1.09, 0.50–2.36; P = 0.83), unplanned revascularization (1.09, 0.83–1.41; P = 0.54), and stroke (1.16, 0.62–2.19; P = 0.64). In conclusion, de-escalation of antiplatelet therapy is associated with nonsignificant differences in both ischemic events and major bleeding compared with standard potent antiplatelet therapy in patients undergoing percutaneous coronary intervention. The feasibility and even superiority of this strategy need to be elucidated by further randomized trials.
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Li et al. (2019) conducted a meta-analysis in Percutaneous coronary intervention (n=17,896). De-escalation of antiplatelet therapy (switching from potent P2Y12 blocker to clopidogrel) vs. Standard potent antiplatelet therapy was evaluated on Major adverse cardiovascular events (MACE) (OR 0.91, 95% CI 0.73-1.14, p=0.43). De-escalation from a potent P2Y12 blocker to clopidogrel resulted in nonsignificant differences in MACE (OR 0.91; 95% CI 0.73-1.14; P=0.43) and major bleeding compared with standard therapy.
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