Key result
Prasugrel significantly reduced the composite risk of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke by 20% compared to clopidogrel in patients with diabetes and acute coronary syndrome (RR 0.80).
Why the study?
Patients with diabetes have worse mortality and morbidity outcomes following ACS, and the optimum P2Y12 blockade strategy in this population was unclear.
Do P2Y12 inhibitors reduce the composite of cardiovascular death, MI, and stroke in adult patients with diabetes and acute coronary syndrome?
Meta-Analysis
Do P2Y12 inhibitors reduce the composite of cardiovascular death, MI, and stroke in adult patients with diabetes and acute coronary syndrome?
Relative Risk: 0.8 (95% CI 0.66–0.97)
In patients with diabetes and ACS, P2Y12 inhibitors are superior to placebo, with newer agents like prasugrel showing a trend toward better outcomes than ticagrelor, particularly in those undergoing PCI.
Supports prasugrel over clopidogrel in diabetic ACS; confirms and extends RCT evidence for potent P2Y12 inhibition in this subgroup.
BACKGROUND: Patients with diabetes are at increased risk of acute coronary syndromes (ACS) and their mortality and morbidity outcomes are significantly worse following ACS events, independent of other comorbidities. This systematic review sought to establish the optimum management strategy with focus on P2Y12 blockade in patients with diabetes with ACS. METHODS: MEDLINE (1946 to present) and EMBASE (1974 to present) databases, abstracts from major cardiology conferences and previously published systematic reviews were searched to June 2014. Relevant randomised control trials with clinical outcomes for P2Y12 inhibitors in adult patients with diabetes with ACS were scrutinised independently by 2 authors with applicable data was extracted for primary composite end point of cardiovascular death, myocardial infarction (MI) and stroke; enabling calculation of relative risks with 95% CI with subsequent direct and indirect comparison. RESULTS: Four studies studied clopidogrel in patients with diabetes, with two (3122 patients) having primary outcome data showing superiority of clopidogrel against placebo with RR0.84 (95% CI 0.72-0.99). Irrespective of management strategy, the newer agents prasugrel (2 studies) and ticagrelor (1 study) had a lower primary event rate compared with clopidogrel; RR 0.80 (95% CI 0.66 to 0.97) and RR 0.89 (95% CI 0.77 to 1.02), respectively. When ticagrelor was indirectly compared with prasugrel, there was a trend to an improved primary outcome with prasugrel (RR 1.11 (95% CI 0.94 to 1.31)) particularly in those managed with percutaneous coronary intervention (PCI) (RR 1.23 (95% CI 0.95 to 1.59)). Prasugrel demonstrated a statistical superiority with prevention of further MI with RR 1.48 (95% CI 1.11 to 1.97). This was not at the expense of increased major thrombolysis in MI (TIMI) bleeding rates RR 0.94 (95% CI 0.59 to 1.51). CONCLUSIONS: This meta-analysis shows the addition of a P2Y12 inhibitor is superior to placebo, with a trend favouring the use of prasugrel in patients with diabetes with ACS, particularly those undergoing PCI.
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Rossington et al. (2016) conducted a meta-analysis in acute coronary syndrome in patients with diabetes. Prasugrel vs. Clopidogrel was evaluated on composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke (RR 0.80, 95% CI 0.66-0.97). Prasugrel significantly reduced the composite risk of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke by 20% compared to clopidogrel in patients with diabetes and acute coronary syndrome (RR 0.80).
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