Early vs. Delayed Initiation of Treatment With P2Y 12 Inhibitors in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Frontiers in Cardiovascular Medicine

article

Lourdes Vicent¹  Carlos Diaz-Arocutipa³  Giuseppe Tarantini⁴  Marco Mojoli⁵  Adrian V. Hernandez³  Héctor Bueno¹ 

[1] Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre;Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares;Vicerrectorado de Investigación, Universidad San Ignacio de Loyola;Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School;Cardiology Department, Azienda Ospedaliera Friuli Occidentale;Health Outcomes, Policy, and Evidence Synthesis ,(HOPES) Group, University of Connecticut School of Pharmacy;Centro Nacional de Investigaciones Cardiovasculares;Facultad de Medicina, Universidad Complutense de Madrid

关键词: clopidogrel;    prasugrel;    ticagrelor;    P2Y 12 inhibitors;    Non-ST-segment elevation acute coronary syndrome;    network meta-analysis;   

DOI  :  10.3389/fcvm.2022.862452

学科分类：地球科学(综合)

来源: Frontiers

【 摘 要 】

Aims Whether early or delayed dual antiplatelet therapy initiation is better in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is unclear. We assessed the evidence for comparing the efficacy and safety of early vs. delayed P2Y 12 inhibitor initiation in NSTE-ACS. Methods The randomized controlled trials with available comparisons between early and delayed initiation of P2Y 12 inhibitors (clopidogrel, prasugrel, and ticagrelor) in patients with NSTE-ACS until January 2021 were reviewed. The primary outcomes were trial-defined major adverse cardiovascular events (MACEs) and bleeding. Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction, stent thrombosis, urgent coronary revascularization, and stroke. Frequentist random-effects network meta-analyses were conducted, ranking best treatments per outcome with p -scores. Results A total of nine trials with intervention arms including early and delayed initiation of clopidogrel ( n = 5), prasugrel ( n = 8), or ticagrelor ( n = 6) involving 40,096 patients were included. Early prasugrel (hazard ratio [HR], 0.59; 95% confidence interval [95%CI], 0.40–0.87), delayed prasugrel (HR, 0.60; 95%CI 0.43–0.84), and early ticagrelor (HR, 0.84; 95%CI, 0.74–0.96) significantly reduced MACE compared with early clopidogrel, but increased bleeding risk. Delayed prasugrel ranked as the best treatment to reduce MACE ( p -score=0.80), early prasugrel to reduce all-cause mortality, cardiovascular mortality, stent thrombosis, and stroke, and delayed clopidogrel to reduce bleeding ( p -score = 0.84). The risk of bias was low for all trials. Conclusion In patients with NSTE-ACS, delayed prasugrel initiation was the most effective strategy to reduce MACE. Although early prasugrel was the best option to reduce most secondary cardiovascular outcomes, it was associated with the highest bleeding risk. The opposite was found for delayed clopidogrel.

【 授权许可】

CC BY