Ding Jing-Wen, Chen Yang, Yu Zuo-Zhong, Zhao Yuan-Bin, Fan Kun-Peng, Yao Xiong-Da, Hu Long-Long, Liao Yan-Hui, Deng Tian-Hua, Xia Yi, Liao Han-Hui, Yang Ren-Qiang
Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, 330006 Nanchang, Jiangxi, China.
Institute of Cardiovascular Diseases, Nanchang University, 330006 Nanchang, Jiangxi, China.
Rev Cardiovasc Med. 2022 Oct 25;23(11):360. doi: 10.31083/j.rcm2311360. eCollection 2022 Nov.
Dual antiplatelet therapy (DAPT) with potent P2Y12 inhibitor is the cornerstone of acute coronary syndrome (ACS) management. Balancing the effects of different strategies of antiplatelet therapy including DAPT de-escalation, potent P2Y12 inhibitor monotherapy, and conventional DAPT is a hot topic.
A systematic search was conducted from the MEDLINE, PubMed, and Embase through October 2021 to identify various DAPT strategies in randomized controlled trials (RCTs) for treatment of ACS patients after undergoing PCI with drug-eluting stent (DES). The network meta-analysis was performed to investigate the net clinic benefit of the DAPT de-escalation, potent P2Y12 inhibitor monotherapy, as well as conventional DAPT. The primary outcome was net adverse clinical events, defined as a composite of major bleeding and cardiac death, myocardial infarction, stroke, stent thrombosis, or target-vessel revascularization. The secondary outcomes include major adverse cardiac events and trial-defined major or minor bleeding.
A total of 14 RCTs with 63,982 patients were included. The DAPT de-escalation was associated with a lower risk of the primary outcome compared with potent P2Y12 inhibitor monotherapy (De-escalation vs monotherapy odds ratio (OR): 0.72 95% confidence interval (CI): 0.55-0.96), and other antiplatelet strategies (De-escalation vs clopidogrel + aspirin OR: 0.49 95% CI: 0.39-0.63; De-escalation vs prasugrel + aspirin OR: 0.76 95% CI: 0.59-0.98; De-escalation vs ticagrelor + aspirin OR: 0.76 95% CI: 0.55-0.90). There were no statistical differences in the incidence of bleeding (DAPT de-escalation vs P2Y12 inhibitor monotherapy OR: 0.73 95% CI: 0.47-1.12) and major adverse cardiac events (DAPT de-escalation vs P2Y12 inhibitor monotherapy OR: 0.79 95% CI: 0.59-1.08) between DAPT de-escalation and potent P2Y12 inhibitor monotherapy.
This network meta-analysis showed that DAPT de-escalation would reduce the net adverse clinical events, compared with potent P2Y12 inhibitor monotherapy, for ACS patients undergone PCI treatment.
使用强效P2Y12抑制剂的双联抗血小板治疗（DAPT）是急性冠状动脉综合征（ACS）管理的基石。平衡包括DAPT降阶梯治疗、强效P2Y12抑制剂单药治疗和传统DAPT在内的不同抗血小板治疗策略的效果是一个热门话题。
通过检索MEDLINE、PubMed和Embase至2021年10月的文献，以确定在接受药物洗脱支架（DES）PCI治疗的ACS患者的随机对照试验（RCT）中的各种DAPT策略。进行网络荟萃分析以研究DAPT降阶梯治疗、强效P2Y12抑制剂单药治疗以及传统DAPT的净临床获益。主要结局是净不良临床事件，定义为大出血与心源性死亡、心肌梗死、卒中、支架血栓形成或靶血管血运重建的复合事件。次要结局包括主要不良心脏事件以及试验定义的严重或轻微出血。
共纳入14项RCT，涉及63982例患者。与强效P2Y12抑制剂单药治疗相比，DAPT降阶梯治疗的主要结局风险更低（降阶梯治疗与单药治疗的比值比（OR）：0.72，95%置信区间（CI）：0.55 - 0.96），与其他抗血小板策略相比也是如此（降阶梯治疗与氯吡格雷 + 阿司匹林相比，OR：0.49，95% CI：0.39 - 0.63；降阶梯治疗与普拉格雷 + 阿司匹林相比，OR：0.76，95% CI：0.59 - 0.98；降阶梯治疗与替格瑞洛 + 阿司匹林相比，OR：0.76，95% CI：0.55 - 0.90）。DAPT降阶梯治疗与强效P2Y12抑制剂单药治疗在出血发生率（降阶梯治疗与P2Y12抑制剂单药治疗相比，OR：0.73，95% CI：0.47 - 1.12）和主要不良心脏事件发生率（降阶梯治疗与P2Y12抑制剂单药治疗相比，OR：0.79，95% CI：0.59 - 1.08）方面无统计学差异。
这项网络荟萃分析表明，对于接受PCI治疗的ACS患者，与强效P2Y12抑制剂单药治疗相比，DAPT降阶梯治疗可减少净不良临床事件。
