Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1, 48033, Cotignola, Italy.
Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico ‛Rodolico-San Marco', University of Catania, 95100, Catania, Italy.
Eur Heart J Cardiovasc Pharmacother. 2024 Nov 6;10(7):588-598. doi: 10.1093/ehjcvp/pvae057.
P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy (DAPT) may balance ischaemic and bleeding risks in patients with acute coronary syndrome (ACS). However, it remains uncertain how different P2Y12 inhibitors used as monotherapy affect outcomes.
Randomized controlled trials comparing P2Y12 inhibitor monotherapy after a short course of DAPT (≤3 months) vs. 12-month DAPT in ACS were included. The primary endpoint was major adverse cardiovascular events (MACE). All analyses included an interaction term for the P2Y12 inhibitor used as monotherapy. Trial sequential analyses were run to explore whether the effect estimate of each outcome may be affected by further studies. Seven trials encompassing 27 284 ACS patients were included. Compared with 12-month DAPT, P2Y12 inhibitor monotherapy after a short course of DAPT was associated with no difference in MACE [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.76-1.12] and a significant reduction in net adverse clinical events (NACE) (OR 0.75; 95% CI 0.60-0.94), any bleeding (OR 0.54, 95% CI 0.43-0.66), and major bleeding (OR 0.47, 95% CI 0.37-0.60). Significant interactions for subgroup difference between ticagrelor and clopidogrel monotherapy were found for MACE (Pint = 0.016), all-cause death (Pint = 0.042), NACE (Pint = 0.018), and myocardial infarction (Pint = 0.028). Trial sequential analysis showed conclusive evidence of improved NACE with ticagrelor, but not with clopidogrel monotherapy, compared with standard DAPT.
In patients with ACS, P2Y12 inhibitor monotherapy after short DAPT halves bleeding without increasing ischaemic events compared with standard DAPT. Ticagrelor, but not clopidogrel monotherapy, reduced MACE, NACE, and mortality compared with standard DAPT, supporting its use after aspirin discontinuation.
在急性冠脉综合征（ACS）患者中，双联抗血小板治疗（DAPT）后短期应用 P2Y12 抑制剂单药治疗可能平衡缺血和出血风险。然而，不同 P2Y12 抑制剂作为单药治疗的效果仍不确定。
纳入比较 DAPT（≤3 个月）后 P2Y12 抑制剂单药治疗与 ACS 12 个月 DAPT的随机对照试验。主要终点是主要不良心血管事件（MACE）。所有分析均包含作为单药治疗的 P2Y12 抑制剂的交互项。进行试验序贯分析以探讨每个结局的效应估计是否可能受到进一步研究的影响。纳入 7 项试验共 27284 例 ACS 患者。与 12 个月 DAPT 相比，DAPT 后短期应用 P2Y12 抑制剂单药治疗与 MACE 无差异[比值比（OR）0.92，95%置信区间（CI）0.76-1.12]和净不良临床事件（NACE）显著减少（OR 0.75；95%CI 0.60-0.94）、任何出血（OR 0.54，95%CI 0.43-0.66）和大出血（OR 0.47，95%CI 0.37-0.60）。替格瑞洛和氯吡格雷单药治疗的亚组差异的交互作用有统计学意义，包括 MACE（Pint=0.016）、全因死亡（Pint=0.042）、NACE（Pint=0.018）和心肌梗死（Pint=0.028）。试验序贯分析显示，与标准 DAPT 相比，替格瑞洛单药治疗可显著改善 NACE，而氯吡格雷单药治疗则无显著改善。
在 ACS 患者中，与标准 DAPT 相比，DAPT 后短期应用 P2Y12 抑制剂单药治疗可将出血减半而不增加缺血事件。与标准 DAPT 相比，替格瑞洛而非氯吡格雷单药治疗可降低 MACE、NACE 和死亡率，支持其在阿司匹林停药后应用。
