Potent Up-Front Antiplatelet Therapy Lowers Mortality for Patients With ACS

Platelet quiescence achieved by up-front potent antiplatelet therapy reduced mortality among patients with acute coronary syndrome (ACS). These findings from a systematic review and meta-analysis were published in the Journal of the American Heart Association.

To date, no randomized study of whether or not platelet quiescence, which is the inhibition residual platelets, successfully delays coronary artery bypass graft surgery (CABG) intervention and induces ischemic protection.

Researchers from the University of Ottawa Heart Institute searched publication databases through April 2019 for studies of platelet inhibitors, ACS, and CABG. The analysis included a total of 6 nonrandomized and 4 randomized controlled trials.

The studies were of clopidogrel vs aspirin (n=4), P2Y₁₂ receptor inhibitors (ticagrelor or prasugrel) vs clopidogrel (n=4), and glycoprotein IIb/IIIa inhibitors vs aspirin (n=2).

Stratified by design, the nonrandomized studies found no association between weaker antiplatelet strategies and mortality (odds ratio [OR] 1.11 [95% CI, 0.8-1.54]; P =.54; I^{2 =} 0). The randomized studies observed weaker antiplatelet strategies increased risk for mortality (OR 1.79 [95% CI, 1.14-2.81]; P =.01).

For the pooled analysis with both randomized and nonrandomized study designs, weaker antiplatelet strategies were associated with an increased risk for mortality (OR 1.38 [95% CI, 1.03-1.85]; P =.03; I² =39%).

One of the studies (the Platelet Inhibition and Patient Outcomes trial) demonstrated some mortality benefit for the use of ticagrelor over clopidogrel among patients who discontinued antiplatelet therapy 1 to 4 days before surgical intervention.

This study was limited by the fact that randomization did not correct for whether or not patients required CABG. Surgical status may have affected estimates of mortality.

The study authors concluded that more potent antiplatelet inhibition before CABG reduced mortality. These findings were consistent with the hypothesis of platelet quiescence, supporting the use of up-front potent antiplatelet regimens among patients with ACS.

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

Reference

Sarathy K, Wells G A, Singh K, et al. Platelet quiescence in patients with acute coronary syndrome undergoing coronary artery bypass graft surgery. J Am Heart Assoc. 2021;10(5):e016602. doi:10.1161/JAHA.120.016602