Antiplatelet De-escalation Favored Over Potent DAPT Following PCI for ACS

A systematic review and meta-analysis published in Circulation: Cardiovascular Interventions found that, for patients with acute coronary syndrome (ACS) recieving percutaneous coronary intervention (PCI), antiplatelet de-escalation therapy is associated with superior mortality and bleeding outcomes compared with potent dual antiplatelet therapy (DAPT).

Investigators from Universitaria de Bologna in Italy and Yonsei University College of Medicine in South Korea searched publication databases for studies of post-PCI antiplatelet strategies among patients with ACS. A total of 6 trials were included.

The study population comprised 20,837 patients who received de-escalation therapy (n=10,392) or standard therapy (n=10,445). The trials evaluated the de-escalation strategies of standard DAPT therapy for 1 to 3 months, followed by ticagrelor monotherapy (n=3), aspirin plus clopidogrel (n=2), or aspirin plus reduced dose prasugrel (n=1).

During a 1-year follow-up, mortality occurred among 119 de-escalation recipients compared with 160 standard therapy recipients, indicating that de-escalation was associated with decreased mortality risk compared with standard treatment (odds ratio [OR], 0.75; 95% CI, 0.59-0.95; P =.02).

De-escalation therapy also associated with decreased risk for any bleeding (OR, 0.51; 95% CI, 0.37-0.68; P <.0001), major bleeding (OR, 0.59; 95% CI, 0.48-0.72; P <.0001), and net-adverse clinical outcomes (OR, 0.74; 95% CI, 0.64-0.84; P <.0001) and tended to associate with lower risk for cardiovascular mortality (OR, 0.55; 95% CI, 0.30-1.01; P =.05) compared with standard therapy.

No significant difference in myocardial infarction, definite or probable stent thrombosis, stroke, or major adverse cardiovascular event risks were observed on the basis of antithrombosis strategies.

In the network meta-analysis, ticagrelor monotherapy was associated with reduced risk for mortality (OR, 0.74; 95% CI, 0.56-0.96) and major bleeding (OR, 0.55; 95% CI, 0.42-0.72) compared with standard therapy, whereas the aspirin-based treatments were not favored over standard therapy.

The findings of this analysis may not be generalizable, as most of the included studies only recruited patients at lower risk for bleeding.

“…antiplatelet therapy de-escalation after 1 to 3 months of potent DAPT with either reduced potency DAPT or ticagrelor monotherapy was associated with lower rates of all-cause mortality, major bleeding, and NACE [net adverse clinical events], with nonsignificantly different rates of ischemic MACE compared with an uninterrupted 1-year course of aspirin plus prasugrel or ticagrelor, “ the study authors wrote. “Further studies are warranted to examine the optimal timing of DAPT de-escalation after PCI in ACS and to determine whether major differences in safety or effectiveness exist between a reduced potency DAPT versus a ticagrelor (or prasugrel) monotherapy de-escalation regimen.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.