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P2Y12 inhibitor monotherapy after short DAPT in acute coronary syndrome: a systematic review and meta-analysis

2024; Oxford University Press; Volume: 45; Issue: Supplement_1 Linguagem: Inglês

10.1093/eurheartj/ehae666.3338

1522-9645

Mattía Galli, Claudio Laudani, Giovanni Occhipinti, Marco Spagnolo, Felice Gragnano, Domenico D’Amario, Eliano Pio Navarese, Roxana Mehran, Marco Valgimigli, D Capodanno, Dominick J. Angiolillo,

Antiplatelet Therapy and Cardiovascular Diseases

Abstract Background P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy (DAPT) has been proposed as an alternative to standard 12-month DAPT for balancing ischemic and bleeding risks in patients with acute coronary syndrome (ACS). However, it remains uncertain how different P2Y12 inhibitors used as monotherapy affect outcomes. Purpose To explore the clinical impact of different P2Y12 inhibitors as monotherapy versus standard 12-month DAPT. Methods Randomized controlled trials (RCTs) comparing P2Y12 inhibitor monotherapy after a short course of DAPT (≤3 months) versus standard 12-month DAPT in ACS were included. The primary endpoint was major adverse cardiovascular events (MACE). Secondary endpoints included single components of MACE, net adverse clinical events (NACE), any bleeding, and major bleeding. All analyses were run according to the pre-specified subgroup based on the P2Y12 inhibitor used as monotherapy. Results Six RCTs including a total of 23,884 ACS patients were included. Mean DAPT duration in the monotherapy arm was 59 days. Compared with standard 12-month DAPT, P2Y12 inhibitor monotherapy after a short course of DAPT was associated with a significant reduction in any bleeding (odds ratio, OR, 0.55; 95% CI 0.44–0.70) and major bleeding (OR 0.48 95% CI 0.36–0.62) without significant interaction for subgroup differences according to the P2Y12 inhibitor used. There were no differences in MACE (OR 0.92; 95% CI 0.74–1.15) or individual ischemic or mortality endpoints between P2Y12 inhibitor monotherapy and standard DAPT. However, there was a significant subgroup difference (pint=0.013) in MACE according to the agent used, with a reduced risk with ticagrelor (OR 0.82; 95% CI 0.69–0.97) but not with clopidogrel (OR 1.32; 95% CI: 0.94–1.84). Significant subgroup differences between ticagrelor and clopidogrel monotherapy were also found in all-cause death (pint=0.038), NACE (pint=0.030), and myocardial infarction (pint=0.015). Trial sequential analysis showed conclusive evidence of improved NACE with ticagrelor monotherapy, but not with clopidogrel monotherapy, compared with standard DAPT. Conclusions In patients with ACS, P2Y12 inhibitor monotherapy with either ticagrelor or clopidogrel after a short course of DAPT nearly halves bleeding compared with standard DAPT. Ticagrelor, but not clopidogrel monotherapy, reduced ischemic events and NACE compared with standard DAPT, supporting its use after aspirin discontinuation in ACS patients.