Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy.
JACC Cardiovasc Interv. 2022 Nov 28;15(22):2239-2249. doi: 10.1016/j.jcin.2022.08.009. Epub 2022 Oct 26.
It is still unknown which antiplatelet monotherapy should be continued after a period of dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI).
The aim of this study was to compare aspirin vs P2Y inhibitor (P2Y-I) monotherapy after dual antiplatelet therapy (DAPT) discontinuation in patients undergoing percutaneous coronary intervention (PCI).
Randomized studies enrolling patients undergoing PCI with second-generation drug-eluting stents and comparing aspirin or P2Y-I monotherapy after DAPT discontinuation vs prolonged DAPT or aspirin vs P2Y-I monotherapy after DAPT were included. Primary efficacy and safety endpoints were myocardial infarction (MI) and major bleeding (MB), respectively. Point estimates for dichotomous outcomes were pooled using frequentist and Bayesian frameworks. Sensitivity analyses and treatment hierarchy were performed.
Nineteen studies encompassing 73,126 patients were included. The transitivity assumption was met. Under the frequentist framework, patients receiving aspirin had a significantly higher risk for MI compared with P2Y-I monotherapy (risk ratio: 1.32; 95% CI: 1.08-1.62). Compared with DAPT, both monotherapies reduced MB, but only P2Y-I showed equivalent efficacy in preventing MI. No significant differences in MB, death, and other thrombotic outcomes were observed. However, point estimates for the risk for stent thrombosis and stroke favored P2Y-I monotherapy. Consistent results were found in a fixed-effects model and the Bayesian framework, with all models having adequate convergence. P2Y-I vs aspirin monotherapy had the highest probability of being ranked first for reduction of all assessed outcomes.
P2Y-I monotherapy following DAPT discontinuation after PCI is associated with a significantly lower risk for MI and similar risk for MB, suggesting a potentially relevant net clinical benefit vs aspirin monotherapy. These findings strengthen the rationale for further studies directly comparing the 2 monotherapies after DAPT in PCI patients.
在接受经皮冠状动脉介入治疗（PCI）的患者中，双抗血小板治疗（DAPT）结束后，哪种抗血小板单药治疗应继续使用仍不清楚。
本研究旨在比较 DAPT 停药后阿司匹林与 P2Y 抑制剂（P2Y-I）单药治疗在接受 PCI 的患者中的疗效。
纳入了接受第二代药物洗脱支架 PCI 且比较 DAPT 停药后阿司匹林或 P2Y-I 单药治疗与延长 DAPT 或阿司匹林与 P2Y-I 单药治疗的随机研究。主要疗效和安全性终点分别为心肌梗死（MI）和主要出血（MB）。使用经典和贝叶斯框架汇总二分类结局的点估计值。进行了敏感性分析和治疗分层。
共纳入了 19 项研究，涵盖 73126 例患者。满足传递性假设。在经典框架下，与 P2Y-I 单药治疗相比，接受阿司匹林治疗的患者发生 MI 的风险显著升高（风险比：1.32；95%置信区间：1.08-1.62）。与 DAPT 相比，两种单药治疗均降低了 MB，但只有 P2Y-I 显示在预防 MI 方面等效的疗效。未观察到 MB、死亡和其他血栓形成结局的显著差异。然而，点估计值表明支架血栓形成和卒中单药治疗的风险有利于 P2Y-I。在固定效应模型和贝叶斯框架中均得到了一致的结果，所有模型的收敛性均良好。与阿司匹林单药治疗相比，P2Y-I 单药治疗在降低所有评估结局方面具有最高的排名第一的可能性。
PCI 后 DAPT 停药后 P2Y-I 单药治疗与 MI 风险显著降低相关，且与 MB 风险相似，提示与阿司匹林单药治疗相比，可能具有显著的净临床获益。这些发现为进一步在 PCI 患者中直接比较两种单药治疗的研究提供了更强的依据。
