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Dual antiplatelet therapy de-escalation in acute coronary syndrome: an individual patient meta-analysis.

Author information

Affiliations

  • 1. Department Internal Medicine, Division of Cardiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
      Authors
    • Kang J 1
    • Park KW 1
    • Chung J 1
    • Hwang D 1
    • Han JK 1
    • Yang HM 1
    • Kang HJ 1
    • Koo BK 1
    • Kim HS 1
    (9 authors)
  • 2. Department Internal Medicine, University Hospital Munich, Campus Grosshadern, Ludwig-Maximilians-University Munich (LMU Munich), Munich, 80539, Germany.
      Authors
    • Rizas KD 2
    • Massberg S 2
    • Sibbing D 2
    (3 authors)
  • 3. Department of Cardiology, St. Antonius Hospital, 3435CM Nieuwegein, The Netherlands.
      Authors
    • van den Broek W 3
    • Claassens DMF 3
    • Ten Berg JM 3
    (3 authors)
  • 4. Department Internal Medicine, Division of Cardiology, Seoul St. Mary's Hospital, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea.
      Authors
    • Choo EH 4
    • Chang K 4
    (2 authors)
  • 5. Department of Cardiology, Semmelweis University, Gyógy tér 2 8230 Balatonfüred, Budapest, Hungary.
      Authors
    • Aradi D 5
    (1 author)

ORCIDs linked to this article

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European Heart Journal, 01 Apr 2023, 44(15):1360-1370
https://doi.org/10.1093/eurheartj/ehac829 PMID: 36883613 

A comment on this article appears in "Comparison of standard ticagrelor and prasugrel therapies based on previous trials." Eur Heart J. 2023 Aug 22;44(32):3102-3103. A comment on this article appears in "Comparison of bleeding risk between standard ticagrelor and prasugrel therapies without de-escalation strategy." Eur Heart J. 2023 Jul 21;:. A comment on this article appears in "P2Y12 inhibitor intensity de-escalation in patients with acute coronary syndromes." Eur Heart J. 2023 Apr 17;44(15):1371-1373.

Abstract 

Aims

Dual-antiplatelet therapy (DAPT) with aspirin and a potent P2Y12 inhibitor is the standard treatment for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). De-escalation of the potent P2Y12 inhibtor is an appealing concept to balance the ischaemic and bleeding risks after PCI. An individual patient data meta-analysis was performed to compare de-escalation versus standard DAPT in patients with ACS.

Methods and results

Electronic databases, including PubMed, Embase, and the Cochrane database, were searched to identify randomised clinical trials (RCTs) comparing the de-escalation strategy with the standard DAPT after PCI in patients with ACS. Individual patient-level data were collected from the relevant trials. The co-primary endpoints of interest were the ischaemic composite endpoint (a composite of cardiac death, myocardial infarction, and cerebrovascular events) and bleeding endpoint (any bleeding) at 1-year post-PCI. Four RCTs (the TROPICAL-ACS, POPular Genetics, HOST-REDUCE-POLYTECH-ACS, and TALOS-AMI trials) including 10 133 patients were analysed. The ischaemic endpoint was significantly lower in the patients assigned to the de-escalation strategy than in those assigned to the standard strategy (2.3% vs. 3.0%, hazard ratio [HR] 0.761, 95% confidence interval [CI] 0.597-0.972, log rank P = 0.029). Bleeding was also significantly lower in the de-escalation strategy group (6.5% vs. 9.1%, HR 0.701, 95% CI 0.606-0.811, log rank P < 0.001). No significant intergroup differences were observed in terms of all-cause death and major bleeding events. Subgroup analyses revealed that compared to guided de-escalation, unguided de-escalation had a significantly larger impact on bleeding endpoint reduction (P for interaction = 0.007); no intergroup differences were observed for the ischaemic endpoints.

Conclusion

In this individual patient data meta-analysis, DAPT-based de-escalation was associated with both decreased ischaemic and bleeding endpoints. Reduction in bleeding endpoints was more prominent for the unguided than the guided de-escalation strategy.

Study registration number

This study was registered in the PROSPERO (ID: CRD42021245477).

Full text links 

Read article at publisher's site: https://doi.org/10.1093/eurheartj/ehac829

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Funding 

Funders who supported this work.

Seoul National University Hospital (1)