接受 PCI 治疗的急性冠状动脉综合征患者的强效 P2Y12 抑制剂选择和去梗策略：系统回顾和 Meta 分析

IF 2.5 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS CJC Open Pub Date : 2024-05-01 DOI:10.1016/j.cjco.2023.11.024

Laurie-Anne Boivin-Proulx MD, MSc , Kevin R. Bainey MD, MSc , Guillaume Marquis-Gravel MD , Michelle M. Graham MD

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引用次数: 0

摘要

背景在强效嘌呤能受体Y亚型12（P2Y12）抑制剂时代，平衡双重抗血小板疗法（DAPT）的效果仍是急性冠状动脉综合征（ACS）治疗中的一项挑战。方法我们进行了一项系统综述和荟萃分析，分为两个阶段，包括检索2019年至2022年11月期间发表的系统综述。我们纳入了对接受经皮冠状动脉介入治疗的 ACS 患者进行的随机对照试验（RCT），这些试验比较了（i）基于替卡格雷的 DAPT 与基于普拉格雷的 DAPT，以及（ii）P2Y12 抑制剂降级策略。我们关注的结果包括主要不良心血管事件 (MACE)、全因死亡、支架血栓和大出血。我们使用随机效应模型估算了风险比 (RR) 和 95% 置信区间 (CI)。与普拉格雷相比，替卡格雷增加了MACE风险（RR 1.23，95% CI 1.01-1.49，中度确定性），但在死亡、支架血栓或大出血方面无显著差异。在 2 项 RCT（n = 3343）中，比较了 1 个月后基于氯吡格雷的 DAPT 降级与基于强效 P2Y12 抑制剂的 DAPT 持续，氯吡格雷降级并未显著改变 MACE、死亡或支架血栓的发生率，但降低了大出血的发生率（RR 0.51，95% CI 0.28-0.92，高度确定性）。结论根据低确定性证据，与普拉格雷相比，替卡格雷与MACE的增加有关，而在经皮冠状动脉介入治疗后的ACS患者中，使用强效P2Y12抑制剂1个月后改为氯吡格雷与大出血发生率的降低有关，而不会增加血栓形成的结果。

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Potent P2Y12 Inhibitor Selection and De-escalation Strategies in Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention: Systematic Review and Meta-analysis

Background

Balancing the effects of dual antiplatelet therapy (DAPT) in the era of potent purinergic receptor type Y, subtype 12 (P2Y₁₂) inhibitors remains a challenge in the management of acute coronary syndrome (ACS).

Methods

We conducted a systematic review and meta-analysis following a 2-stage process consisting of searching for systematic reviews published between 2019 and November 2022. We included randomized controlled trials (RCTs) of ACS patients treated with percutaneous coronary intervention comparing (i) ticagrelor- vs prasugrel-based DAPT and (ii) P2Y₁₂ inhibitor de-escalation strategies. Outcomes of interest were major adverse cardiovascular events (MACE), all-cause death, stent thrombosis, and major bleeding. We estimated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model.

Results

Eight RCTs (n = 5571) compared ticagrelor to prasugrel. Ticagrelor was associated with an increased risk of MACE compared to prasugrel (RR 1.23, 95% CI 1.01-1.49, moderate certainty), without significant differences in death, stent thrombosis, or major bleeding. In 2 RCTs (n = 3343) comparing clopidogrel-based DAPT de-escalation after 1 month to potent P2Y₁₂ inhibitor–based DAPT continuation, clopidogrel de-escalation did not significantly alter the incidence of MACE, death, or stent thrombosis, but reduced that of major bleeding (RR 0.51, 95% CI 0.28-0.92, high certainty). The effect of prasugrel dose de-escalation was inconclusive for all outcomes based on one trial.

Conclusions

Ticagrelor was associated with an increase in MACE compared with prasugrel, based on low-certainty evidence, whereas de-escalation to clopidogrel after 1 month of potent P2Y₁₂ inhibitor was associated with a decrease in incidence of major bleeding without increasing thrombotic outcomes in ACS patients post-percutaneous coronary intervention.

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