Key result
Antiplatelet de-escalation to clopidogrel cuts bleeding or thrombotic events ~36% versus continuation.
Why the study?
Does antiplatelet de-escalation improve net clinical outcomes compared with continuation of potent P2Y12 blockade in patients with acute coronary syndrome undergoing PCI?
Meta-Analysis (n=3,391)
Does antiplatelet de-escalation improve net clinical outcomes compared with continuation of potent P2Y12 blockade in patients with acute coronary syndrome undergoing PCI?
Relative Risk: 0.64 (95% CI 0.43–0.97)
Absolute Event Rate: 8.7% vs 12.1%
p-value: p=.03
De-escalation of antiplatelet therapy to clopidogrel shortly after PCI in ACS patients provides a net clinical benefit by reducing bleeding or thrombotic events without increasing the risk of MACE.
Supports de-escalation to clopidogrel shortly after PCI in ACS; confirms net clinical benefit over continued potent P2Y12 inhibition.
Aims: Patients with acute coronary syndrome undergoing percutaneous coronary intervention (PCI) are recommended to be placed on potent P2Y12 blockade. However, the long-term bleeding risk is high. Therefore, despite no definitive evidence, switching to clopidogrel beyond the acute phase is common. We aimed to evaluate the clinical outcomes of antiplatelet de-escalation compared with continuation in patients treated with PCI. Methods: We searched databases for randomized clinical trials (RCTs) that evaluated the safety and efficacy of antiplatelet de-escalation compared with continuation in patients treated with PCI. Pooled summary estimates were calculated. Results: We included 3 RCTs with 3391 patients (median follow-up: 12 months). Compared with the continued group, the net clinical outcome (composite of bleeding or thrombotic events) was significantly reduced in the group switched to clopidogrel (8.7% vs 12.1%; risk ratio [RR]: 0.64; 95% confidence interval [CI]: 0.43-0.97; P = .03). However, there were similar clinical outcomes between groups for major adverse cardiovascular events (MACE; RR: 0.78; 95% CI: 0.55-1.11; P = .17), all Bleeding Academic Research Consortium (BARC) types bleeding (RR: 0.61; 95% CI: 0.33-1.11; P = .10), or BARC types ≥2 bleeding (RR: 0.49; 95% CI: 0.19-1.26; P = .14). Conclusions: Our results suggest a net clinical benefit of de-escalation therapy shortly after PCI, without increased risk of MACE. Larger randomized trials will be necessary to confirm these findings.
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Kheiri et al. (2018) conducted a meta-analysis in Acute coronary syndrome undergoing percutaneous coronary intervention (n=3,391). Antiplatelet de-escalation (switching to clopidogrel) vs. Continuation of potent P2Y12 blockade was evaluated on Net clinical outcome (composite of bleeding or thrombotic events) (RR 0.64, 95% CI 0.43-0.97, p=.03). Antiplatelet de-escalation to clopidogrel significantly reduced the composite of bleeding or thrombotic events compared with continuation (8.7% vs 12.1%; RR 0.64; 95% CI 0.43-0.97; P=0.03).
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