Comparison of Unguided De-Escalation Versus Guided Selection of Dual Antiplatelet Therapy After Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis.

Toshiki Kuno, Tomohiro Fujisaki, Satoshi Shoji, Yuki Sahashi, Yusuke Tsugawa, Masao Iwagami, Hisato Takagi, Alexandros Briasoulis, Pierre Deharo, Thomas Cuisset, Azeem Latib, Shun Kohsaka, Deepak L Bhatt
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引用次数: 0

Abstract

Background: The benefit of dual antiplatelet therapy (DAPT) for reducing ischemic events is greatest in the early period of acute coronary syndrome, and recent randomized controlled trials have investigated the unguided de-escalation strategy of changing potent P2Y12 inhibitors to less potent or reduced-dose P2Y12 inhibitors 1 month after acute coronary syndrome. However, it remains unclear which strategy is more effective and safer: the uniform unguided de-escalation strategy versus the personalized guided selection of DAPT with genotype or platelet function tests.

Methods: PubMed, EMBASE, and Cochrane Central were searched for articles published from database inception to September 10, 2021. Randomized controlled trials investigating DAPT using clopidogrel, low-dose prasugrel, standard-dose prasugrel, ticagrelor, unguided de-escalation strategy, and guided selection strategy for patients with acute coronary syndrome were included. Hazard ratios and relative risk estimates were extracted from each study. The estimates were pooled using a random-effects network meta-analysis. The primary efficacy outcome was major adverse cardiovascular events, defined as a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major or minor bleeding. Secondary outcomes were all-cause death, cardiovascular death, myocardial infarction, stroke, stent thrombosis, and major bleeding.

Results: This study included 19 randomized controlled trials with 69 746 patients. Compared with guided selection of DAPT, unguided de-escalation of DAPT was associated with a decreased risk of the primary safety outcome (hazard ratio, 0.48 [95% CI, 0.33-0.72]) without increased risks of major adverse cardiovascular events (hazard ratio, 0.82 [95% CI, 0.53-1.28]) or any secondary outcomes. The results were similar when the guided selection strategy was divided into platelet function-guided and genotype-guided strategies.

Conclusions: Compared with guided selection of DAPT, unguided de-escalation of DAPT decreased bleeding without increasing ischemic events in patients after acute coronary syndrome. If a strategy of de-escalation is chosen, these findings do not support the routine use of personalized guiding tests.

Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42021273082.

急性冠脉综合征后非引导降压与引导选择双重抗血小板治疗的比较:系统回顾和网络荟萃分析。
背景:双重抗血小板治疗(DAPT)在急性冠状动脉综合征早期减少缺血事件的益处最大,最近的随机对照试验研究了急性冠状动脉综合征后1个月将强效P2Y12抑制剂改为弱效或减少剂量的P2Y12抑制剂的无指导降压策略。然而,目前尚不清楚哪一种策略更有效和更安全:统一的无指导的降级策略与个性化的指导选择DAPT基因型或血小板功能测试。方法:检索PubMed、EMBASE和Cochrane Central从数据库建立到2021年9月10日发表的文章。纳入随机对照试验,研究急性冠脉综合征患者使用氯吡格雷、低剂量普拉格雷、标准剂量普拉格雷、替卡格雷、非引导降压策略和引导选择策略的DAPT。从每项研究中提取风险比和相对风险估计值。这些估计值是用随机效应网络元分析汇总的。主要疗效终点是主要心血管不良事件,定义为心血管死亡、心肌梗死或中风的复合。主要的安全结局是大出血或轻微出血。次要结局是全因死亡、心血管死亡、心肌梗死、中风、支架血栓形成和大出血。结果:本研究纳入19项随机对照试验,共69 746例患者。与有指导的DAPT选择相比,无指导的DAPT降级与主要安全结局(风险比,0.48 [95% CI, 0.33-0.72])的风险降低相关,而不增加主要不良心血管事件(风险比,0.82 [95% CI, 0.53-1.28])或任何次要结局的风险。将引导选择策略分为血小板功能引导策略和基因型引导策略时,结果相似。结论:与有指导选择DAPT相比,无指导降压DAPT可减少急性冠状动脉综合征患者出血,且不增加缺血事件。如果选择降级策略,这些发现不支持常规使用个性化引导测试。注册:网址:https://www.crd.york.ac.uk/PROSPERO/;唯一标识符:CRD42021273082。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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