Best antiplatelet agent for long-term secondary prevention in patients with established infection coronary artery disease (CAD) could possibly be P2Y12 inhibitors such as Clopidogrel again ticagrelor than that aspirinsuggesting a patient-level meta-analysis of seven randomized trials.
More than 24,000 patients included in a meta-analysis called PANTHER had previously documented stable CAD. myocardial infarction (MI), or recent or remote surgical or percutaneous coronary revascularization.
Approximately half of the patients in each antiplatelet monotherapy trial received clopidogrel or ticagrelor, and the other half received aspirin. Follow-up periods ranged from 6 months to 3 years.
People who use P2Y12 Inhibitors showed a 12% reduction in risk (P. = .012) for the primary efficacy outcomes, cardiovascular (CV) death, MI, and stroke, with a median of about 1.35 years or more. This difference was primarily caused by a 23% reduction in the risk of MI (P. < .001); mortality did not appear to be affected by antiplatelet treatment assignment.
Although it is P2Y,12 The inhibitor and aspirin groups were similar with respect to the risk of major bleeding, P2Y.12 The inhibitor group had gastrointestinal (GI) bleeding, overt stent thrombosis, and hemorrhagic strokethe incidence of hemorrhagic stroke was well below 1% in both groups.
Treatment effects were consistent across patient subgroups, including whether aspirin was compared with clopidogrel or ticagrelor.
“Together, our data question the central role of aspirin in secondary prevention and support a paradigm shift towards P2Y.”12 Inhibitor monotherapy as a long-term antiplatelet strategy in a substantial number of patients coronary artery atherosclerosissaid Felice Gragnano, M.D. heart.org | Medscape Cardiology. “Given the [their] Overall safety as good as efficacy, P2Y12 inhibitors may be preferred [over] Aspirin for cardiovascular event prevention in CAD patients. ”
Gragnano of the University of Campania Luigi Vanvitelli in Caserta, Italy, called PANTHER “the largest and most comprehensive synthesis of individual patient data from randomized trials comparing P2Y.”12 Inhibitor Monotherapy Versus Aspirin Monotherapy” is the lead author of the study. publish online July 3 Journal of the American College of Cardiology.
Current guidelines recommend aspirin as antiplatelet monotherapy for patients with established CAD, but “the superiority of aspirin in secondary prevention is based on historical trials conducted in the 1970s and 1980s. , may not apply to modern practice,” Gragnano said.
Furthermore, in subsequent studies comparing P2Y,12 Inhibitors combined with aspirin as secondary prevention produced ‘inconsistent results’. This is probably due to the heterogeneous population of patients with coronary artery disease, cerebrovascular disease, or cerebrovascular disease. peripheral vascular disease, He said. Research-level meta-analyses in this area “do not provide conclusive evidence” because they have not evaluated treatment effects exclusively in patients with established CAD.
Most of the 24,325 participants in the seven trials had a history of MI and some had peripheral arterial disease (PAD). The percentages were 56.2% and 9.1% respectively. Percutaneous or surgical coronary revascularization was performed in approximately 70%. Most (61%) presented: acute coronary syndromeThe rest presented with chronic CAD.
Approximately 76% of the total cohort were from Europe or North America. The rest were participants from Asia. The average age of patients was 64 years, and approximately 22% were female.
A total of 12,175 people were assigned to P2Y12 Inhibitor monotherapy (62% received clopidoglem and 38% received ticagrelor). 12,147 received aspirin at doses ranging from 75 mg to 325 mg per day.
Primary Efficacy Outcome, P2Y Hazard Ratio (HR)12 0.88 (95% CI, 0.79 – 0.97; P. = .012); the report stated that the number needed to treat (NNT) to prevent one major event over 2 years was 121.
HR corresponding to MI was 0.77 (95% CI, 0.66–0.90; P. < .001), the NNT profit was 136. For net adverse clinical events, the HR was 0.89 (95% CI, 0.81–0.98; P. = .020), the NNT merit is 121.
There was no significant difference in the risk of major bleeding (HR, 0.87; 95% CI, 0.70 – 1.09; P. = .23) and no risk of stroke (HR, 0.84; 95% CI, 0.70 – 1.02; P. = .076) or cardiovascular death (HR, 1.02; 95% CI, 0.86 – 1.20; P. = .82).
Still, P2Y12 The inhibitor group showed a significantly reduced risk of:
-
Gastrointestinal bleeding: HR, 0.75 (95% CI, 0.57 – 0.97; P. = .027)
-
Definite stent thrombosis: HR, 0.42 (95% CI, 0.19 – 0.97; P. = .028)
-
Hemorrhagic stroke: HR, 0.43 (95% CI, 0.23 – 0.83; P. = .012)
The results of the current study are “hypothetical but not definitive,” said Durham Kumbani, M.D., Ph.D., of the University of Texas at Southwestern University, Dallas. heart.org | Medscape Cardiology.
‘Aspirin or P2Y still unclear’12 Inhibitor monotherapy is suitable for long-term maintenance use in patients with established CAD. Aspirin has historically been the drug of choice for this condition,” said Kumbani, who wrote a paper with James A. de Lemos, M.D., of the same facility. Edit attachment Panther report.
“It would certainly be appropriate to consider P2Y.”12 Monotherapy is preferentially applied to patients with previous or current high risk of gastrointestinal disease. intracranial hemorrhageFor example,” Kumbani said. For the rest, aspirin and P2Y12 Both inhibitors are “reasonable substitutes”.
In an editorial, Kumbhani and de Lemos called the PANTHER meta-analysis “a well-conducted study with potentially important clinical implications.” The findings are “biologically rational. P2Y12 inhibitors are more potent antiplatelet agents than aspirin and have less impact on gastrointestinal mucosal integrity.”
But for now, they write “both aspirin and P2Y.”12 Inhibitors remain a potent alternative for the prevention of atherothrombotic events in patients with established CAD. ”
Gragnano had no disclosures. Potential conflicts with other authors are noted in the report. Mr Kumbani did not report the connection. de Lemos has received honoraria from Eli Lilly, Novo Nordisk, AstraZeneca and Janssen for participating in the Data Security Oversight Board.
J. am col cardiole. It will be published online on July 3, 2023. overview, editorial
Bhatia Swift Yasgar (LSW, Massachusetts) is a freelance writer practicing counseling in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and has authored several consumer health books, as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom. (Memoirs of Two Brave Afghans). sisters she told her stories of themselves).
Follow Medscape for more news Facebook, twitter, InstagramYouTube.
