Shah Rahman, Rashid Abdul, Hwang Inyong, Fan Tai-Hwang M, Khouzam Rami N, Reed Guy L
Section of Cardiology, Department of Medicine, University of Tennessee, School of Medicine, Memphis, Tennessee; Department of Medicine, Veterans Affairs Medical Center, Memphis, Tennessee.
Jackson Clinic, Department of Medicine, University of Tennessee, Jackson, Tennessee.
Am J Cardiol. 2017 Jun 1;119(11):1723-1728. doi: 10.1016/j.amjcard.2017.03.011. Epub 2017 Mar 16.
A cornerstone of medical therapy for patients with acute coronary syndrome (ACS) is dual antiplatelet therapy, which includes aspirin and a P2Y12 inhibitor. Randomized controlled trials (RCTs) have shown that prasugrel and ticagrelor are superior to clopidogrel, but none directly compared these 3 commonly used oral P2Y12 inhibitors for safety and efficacy. Therefore, we performed a Bayesian network meta-analysis of RCTs to compare the efficacies and safeties of 3 commonly used oral P2Y12 inhibitors in patients with ACS. Scientific databases and websites were searched for relevant RCTs. We included data from 9 RCTs that enrolled 106,288 patients. Clopidogrel decreased the rates of major adverse cardiac event, recurrent myocardial infarction, and all-cause mortality compared with placebo. Both ticagrelor and prasugrel decreased the rates for major adverse cardiac event and recurrent myocardial infarction compared with clopidogrel, but there was no difference between the 2. Both also decreased the stent thrombosis rate compared with clopidogrel, but prasugrel was more effective than ticagrelor. Ticagrelor use was also associated with improved all-cause and CV mortalities compared with clopidogrel. There was no difference in CV mortality or all-cause mortality between clopidogrel and prasugrel. Prasugrel use was also associated with significantly increased risk of major bleeding compared with clopidogrel but showed a nonsignificant trend toward increasing the risk of bleeding compared with ticagrelor. In treatment ranking, ticagrelor was the most efficacious, and prasugrel was the least safe. In conclusion, this meta-analysis shows that in patients with ACS, adding P2Y12 inhibitors to aspirin and other standard treatments reduces ischemic events and all-cause mortality. Among the commonly used oral P2Y12 inhibitors, ticagrelor has the best net efficacy and safety profile.
急性冠状动脉综合征（ACS）患者医学治疗的基石是双联抗血小板治疗，其中包括阿司匹林和一种P2Y12抑制剂。随机对照试验（RCT）表明，普拉格雷和替格瑞洛优于氯吡格雷，但尚无研究直接比较这三种常用口服P2Y12抑制剂的安全性和有效性。因此，我们进行了一项RCT的贝叶斯网络荟萃分析，以比较三种常用口服P2Y12抑制剂在ACS患者中的疗效和安全性。检索科学数据库和网站以查找相关RCT。我们纳入了9项RCT的数据，这些研究共纳入106288例患者。与安慰剂相比，氯吡格雷降低了主要不良心脏事件、再发心肌梗死和全因死亡率。与氯吡格雷相比，替格瑞洛和普拉格雷均降低了主要不良心脏事件和再发心肌梗死的发生率，但二者之间无差异。与氯吡格雷相比，二者也均降低了支架血栓形成率，但普拉格雷比替格瑞洛更有效。与氯吡格雷相比，使用替格瑞洛还可改善全因死亡率和心血管死亡率。氯吡格雷和普拉格雷在心血管死亡率或全因死亡率方面无差异。与氯吡格雷相比，使用普拉格雷还与大出血风险显著增加相关，但与替格瑞洛相比，出血风险增加的趋势不显著。在治疗排名中，替格瑞洛最有效，普拉格雷最不安全。总之，这项荟萃分析表明，在ACS患者中，在阿司匹林和其他标准治疗基础上加用P2Y12抑制剂可降低缺血事件和全因死亡率。在常用的口服P2Y12抑制剂中，替格瑞洛具有最佳的净疗效和安全性。
