Department of Pharmacy, Peking University First Hospital, No. 8 of Xishiku Street, Xicheng District, Beijing, 100034, China.
School of Pharmaceutical Sciences, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
J Thromb Thrombolysis. 2024 Jan;57(1):143-154. doi: 10.1007/s11239-023-02875-x. Epub 2023 Aug 7.
The aim of this study was to identify the optimal anti-platelet therapy in older acute coronary syndrome (ACS) patients with a mean age ≥ 60 years by comparing the efficacy and safety of different anti-platelet therapies. The selection of antiplatelet therapy in older patients with ACS is a clinical challenge. Numerous evidences indicate that the de-escalation of dual anti-platelet therapy (DAPT) or P2Y12 inhibitor monotherapy may reduce bleeding risk without increasing thrombotic events. However, there is a lack of systematic reviews and optimal strategy analysis regarding older ACS patients. Randomized controlled trials (RCTs) of anti-platelet therapy in older ACS patients were identified. Major adverse cardiovascular events (MACE) were the primary outcome. Secondary outcomes included all death, cardiovascular death, myocardial infarction, stroke, stent thrombosis, and trial-defined major bleeding. Frequentist and Bayesian network meta-analyses were conducted. Treatments were ranked on posterior probability. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis. A total of 12 RCTs including 59,284 older ACS patients treated with five anti-platelet strategies were included. Ticagrelor monotherapy after 3 months DAPT was comparable to the other strategies (OR 0.73; 95% CI 0.32-1.6) in terms of MACE risk. Additionally, P score analysis and SUCRA Bayesian analysis showed that it was the most beneficial treatment for all deaths, cardiovascular death and revascularization. For safety, although there was no significant difference in direct comparisons, both SUCRA Bayesian (0.806) and P score (0.519) analysis suggested that ticagrelor monotherapy was the safest strategy. The current evidence demonstrated that ticagrelor monotherapy after 3 months DAPT may be a promising approach for achieving a more favorable balance between risk and benefit for older ACS patients, with a relatively low bleeding risk and without an increased risk of MACE events. Moreover, it remains the preferred option for clinical outcomes such as all death, CV death and revascularization. Further high-quality and long-term studies are required to validate anti-platelet therapies among older ACS patients.
本研究旨在通过比较不同抗血小板治疗的疗效和安全性，确定年龄均≥60 岁的老年急性冠脉综合征（ACS）患者的最佳抗血小板治疗方法。老年 ACS 患者的抗血小板治疗选择是一个临床挑战。大量证据表明，双抗血小板治疗（DAPT）或 P2Y12 抑制剂单药治疗的降级可能会降低出血风险，而不会增加血栓事件。然而，对于老年 ACS 患者，缺乏系统的综述和最佳策略分析。我们确定了老年 ACS 患者抗血小板治疗的随机对照试验（RCT）。主要心血管不良事件（MACE）是主要结局。次要结局包括全因死亡、心血管死亡、心肌梗死、卒中和支架血栓形成以及试验定义的大出血。进行了频率论和贝叶斯网络荟萃分析。根据后验概率对治疗方法进行排名。使用贝叶斯网络荟萃分析估计汇总优势比（OR）。共有 12 项 RCT 纳入了 59284 例接受 5 种抗血小板策略治疗的老年 ACS 患者。与其他策略相比（OR 0.73；95%CI 0.32-1.6），DAPT 后 3 个月使用替格瑞洛单药治疗在 MACE 风险方面相当。此外，P 评分分析和 SUCRA 贝叶斯分析表明，对于全因死亡、心血管死亡和血运重建，这是最有益的治疗方法。关于安全性，尽管直接比较没有差异，但 SUCRA 贝叶斯（0.806）和 P 评分（0.519）分析均表明替格瑞洛单药治疗是最安全的策略。目前的证据表明，DAPT 后 3 个月替格瑞洛单药治疗可能是一种有前途的方法，可以在老年 ACS 患者中实现风险和获益之间更有利的平衡，出血风险相对较低，而不会增加 MACE 事件的风险。此外，它仍然是临床结局（如全因死亡、心血管死亡和血运重建）的首选方案。需要进一步开展高质量和长期研究，以验证老年 ACS 患者的抗血小板治疗方法。
