Cardiac Intensive Care Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy.
Unit of Echocardiography, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy.
Am J Cardiol. 2020 Jun 15;125(12):1815-1822. doi: 10.1016/j.amjcard.2020.03.019. Epub 2020 Apr 2.
Dual antiplatelet therapy combining aspirin with a P2Y-receptor inhibitor reduces atherothrombotic events following an acute coronary syndromes (ACS), but the relative merits of different P2Y inhibitors remain unclear, despite several recent large-scale trials. We performed a network meta-analysis, representing the largest evidence to date to inform P2Y inhibitor choice in patients with ACS. Fourteen studies were included, for a total population of 145,019 patients. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review. A network meta-analysis using a frequentist approach with surface under the cumulative ranking probability calculation was performed. Major adverse cardiovascular events (MACE), all-cause death, myocardial infarction (MI), definite stent thrombosis (ST) and major bleeding at 30-day and 1-year all-cause death and MI were the study endpoints. At 30-day, prasugrel was superior to both clopidogrel and ticagrelor in MACE, all-cause death and definite ST endpoints. Both prasugrel and ticagrelor were superior to clopidogrel in MI endpoint. Ticagrelor also reduced all-cause death compared with clopidogrel. Ticagrelor, prasugrel, and clopidogrel resulted equivalent in terms of the safety outcome of 30-day major bleeding. No significant difference was found among clopidogrel, prasugrel, and ticagrelor with respect to 1-year MACE outcome. Both prasugrel and ticagrelor reduced the occurrence of 1-year all-cause death compared with clopidogrel. Prasugrel reduced 1-year MI rate as compared with clopidogrel, while ticagrelor did not. At probability analyses, prasugrel ranked best in all 30-day and 1-year efficacy and safety endpoints. In conclusion, in this network meta-analysis, prasugrel showed the highest efficacy in reducing adverse outcomes in ACS patients and had the highest probability of being the best P2Y inhibitor to reduce hard adverse events both at 30-day and 1-year follow-up.
双联抗血小板治疗（即阿司匹林联合 P2Y 受体抑制剂）可降低急性冠脉综合征（ACS）患者的动脉粥样硬化血栓事件风险，但不同 P2Y 抑制剂的相对优势仍不清楚，尽管最近进行了几项大型试验。我们进行了一项网络荟萃分析，这是迄今为止提供 ACS 患者选择 P2Y 抑制剂信息的最大证据。纳入了 14 项研究，共有 145019 例患者。本系统评价按照系统评价和荟萃分析的首选报告项目进行。使用基于频率的方法和累积排序概率计算进行网络荟萃分析。主要不良心血管事件（MACE）、全因死亡、心肌梗死（MI）、明确的支架血栓形成（ST）和 30 天及 1 年全因死亡和 MI 大出血是研究终点。在 30 天，普拉格雷在 MACE、全因死亡和明确 ST 终点方面优于氯吡格雷和替格瑞洛。普拉格雷和替格瑞洛在 MI 终点方面优于氯吡格雷。与氯吡格雷相比，替格瑞洛也降低了全因死亡。替格瑞洛与氯吡格雷相比，30 天主要出血的安全性结局相当。氯吡格雷、普拉格雷和替格瑞洛在 1 年 MACE 结局方面无显著差异。普拉格雷和替格瑞洛均降低了 1 年全因死亡的发生，与氯吡格雷相比。与氯吡格雷相比，普拉格雷降低了 1 年 MI 发生率，而替格瑞洛则没有。在概率分析中，普拉格雷在所有 30 天和 1 年的疗效和安全性终点中排名最佳。总之，在这项网络荟萃分析中，普拉格雷在降低 ACS 患者不良结局方面显示出最高的疗效，在降低 30 天和 1 年随访期间的硬不良事件方面具有成为最佳 P2Y 抑制剂的最高概率。
