Department of Cardiology, Edogawa Hospital, Tokyo, Japan.
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
Int J Cardiol. 2023 Oct 15;389:131157. doi: 10.1016/j.ijcard.2023.131157. Epub 2023 Jul 9.
Various durations and de-escalation strategies of dual antiplatelet therapy (DAPT) after ST-elevation myocardial infarction (STEMI) or non-ST-elevation acute coronary syndromes (NSTE-ACS) have been tested in randomized controlled trials (RCT)s. However, evidence by specific ACS subtype is unknown.
PubMed, EMBASE, and Cochrane CENTRAL were searched in February 2023. RCTs on DAPT strategies included STEMI or NSTE-ACS patients with standard DAPT (12 months) with clopidogrel or potent P2Y inhibitors, short-term DAPT (≤6 months) followed by potent P2Y inhibitors or aspirin, unguided de-escalation from potent P2Y inhibitors to low-dose potent P2Y inhibitors or clopidogrel at one month, and guided selection with genotype or platelet function tests were identified. The primary outcome was the net adverse clinical events (NACE) defined as a composite of major adverse cardiovascular events (MACE) and clinically relevant bleeding events.
Twenty RCTs with a combined total population of 24,745 STEMI and 37,891 NSTE-ACS patients were included. In STEMI patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with standard DAPT using potent P2Y inhibitors (HR:0.57; 95% CI:0.34-0.96) without increased risk of MACE. In NSTE-ACS patients, unguided de-escalation strategy was associated with a lower rate of NACE compared with the guided selection strategy (HR:0.65; 95% CI:0.47-0.90), standard DAPT using potent P2Y inhibitors (HR:0.62; 95% CI:0.50-0.78) and standard DAPT using clopidogrel (HR:0.73; 95% CI:0.55-0.98) without increased risk of MACE.
Unguided de-escalation strategy was associated with a reduced risk of NACE and may be the most effective DAPT strategy for STEMI and NSTE-ACS.
在随机对照试验（RCT）中已经测试了 ST 段抬高型心肌梗死（STEMI）或非 ST 段抬高型急性冠脉综合征（NSTE-ACS）后双联抗血小板治疗（DAPT）的不同持续时间和降级策略。然而，特定 ACS 亚型的证据尚不清楚。
于 2023 年 2 月在 PubMed、EMBASE 和 Cochrane CENTRAL 进行检索。纳入了 DAPT 策略的 RCT，这些 RCT 纳入了接受标准 DAPT（12 个月）的 STEMI 或 NSTE-ACS 患者，标准 DAPT 包括氯吡格雷或强效 P2Y 抑制剂；短期 DAPT（≤6 个月）后使用强效 P2Y 抑制剂或阿司匹林；1 个月时从强效 P2Y 抑制剂向低剂量强效 P2Y 抑制剂或氯吡格雷无指导降级；以及使用基因分型或血小板功能试验进行有指导的降级。主要结局为净不良临床事件（NACE），定义为主要不良心血管事件（MACE）和临床相关出血事件的复合结局。
纳入了 20 项 RCT，共计 24745 例 STEMI 和 37891 例 NSTE-ACS 患者。在 STEMI 患者中，与使用强效 P2Y 抑制剂的标准 DAPT 相比，无指导降级策略与较低的 NACE 发生率相关（HR：0.57；95%CI：0.34-0.96），并且不增加 MACE 风险。在 NSTE-ACS 患者中，与有指导选择策略相比，无指导降级策略与较低的 NACE 发生率相关（HR：0.65；95%CI：0.47-0.90），与使用强效 P2Y 抑制剂的标准 DAPT（HR：0.62；95%CI：0.50-0.78）和使用氯吡格雷的标准 DAPT（HR：0.73；95%CI：0.55-0.98）相比，与较低的 NACE 发生率相关，并且不增加 MACE 风险。
无指导降级策略与降低 NACE 风险相关，可能是 STEMI 和 NSTE-ACS 最有效的 DAPT 策略。
