Early vs. Delayed Initiation of Treatment With P2Y12 Inhibitors in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials
AimsWhether 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 P2Y12 inhibitor initiation in NSTE-ACS.MethodsThe r...
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| Format: | Article |
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Frontiers Media S.A.
2022-04-01
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| Series: | Frontiers in Cardiovascular Medicine |
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| Online Access: | https://www.frontiersin.org/articles/10.3389/fcvm.2022.862452/full |
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| author | Lourdes Vicent Lourdes Vicent Carlos Diaz-Arocutipa Giuseppe Tarantini Marco Mojoli Adrian V. Hernandez Adrian V. Hernandez Héctor Bueno Héctor Bueno Héctor Bueno Héctor Bueno |
| author_facet | Lourdes Vicent Lourdes Vicent Carlos Diaz-Arocutipa Giuseppe Tarantini Marco Mojoli Adrian V. Hernandez Adrian V. Hernandez Héctor Bueno Héctor Bueno Héctor Bueno Héctor Bueno |
| author_sort | Lourdes Vicent |
| collection | DOAJ |
| description | AimsWhether 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 P2Y12 inhibitor initiation in NSTE-ACS.MethodsThe randomized controlled trials with available comparisons between early and delayed initiation of P2Y12 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.ResultsA 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.ConclusionIn 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. |
| first_indexed | 2024-12-10T10:27:07Z |
| format | Article |
| id | doaj.art-bf9f8c1f93dd4fc9b0585ad5e0fe9fed |
| institution | Directory Open Access Journal |
| issn | 2297-055X |
| language | English |
| last_indexed | 2024-12-10T10:27:07Z |
| publishDate | 2022-04-01 |
| publisher | Frontiers Media S.A. |
| record_format | Article |
| series | Frontiers in Cardiovascular Medicine |
| spelling | doaj.art-bf9f8c1f93dd4fc9b0585ad5e0fe9fed2022-12-22T01:52:41ZengFrontiers Media S.A.Frontiers in Cardiovascular Medicine2297-055X2022-04-01910.3389/fcvm.2022.862452862452Early vs. Delayed Initiation of Treatment With P2Y12 Inhibitors in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled TrialsLourdes Vicent0Lourdes Vicent1Carlos Diaz-Arocutipa2Giuseppe Tarantini3Marco Mojoli4Adrian V. Hernandez5Adrian V. Hernandez6Héctor Bueno7Héctor Bueno8Héctor Bueno9Héctor Bueno10Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, SpainCentro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, SpainVicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, PeruDepartment of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, ItalyCardiology Department, Azienda Ospedaliera Friuli Occidentale, Pordenone, ItalyVicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, PeruHealth Outcomes, Policy, and Evidence Synthesis (HOPES) Group, University of Connecticut School of Pharmacy, Storrs, CT, United StatesCardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, SpainCentro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, SpainCentro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, SpainFacultad de Medicina, Universidad Complutense de Madrid, Madrid, SpainAimsWhether 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 P2Y12 inhibitor initiation in NSTE-ACS.MethodsThe randomized controlled trials with available comparisons between early and delayed initiation of P2Y12 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.ResultsA 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.ConclusionIn 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.https://www.frontiersin.org/articles/10.3389/fcvm.2022.862452/fullclopidogrelprasugrelticagrelorP2Y12 inhibitorsNon-ST-segment elevation acute coronary syndromenetwork meta-analysis |
| spellingShingle | Lourdes Vicent Lourdes Vicent Carlos Diaz-Arocutipa Giuseppe Tarantini Marco Mojoli Adrian V. Hernandez Adrian V. Hernandez Héctor Bueno Héctor Bueno Héctor Bueno Héctor Bueno Early vs. Delayed Initiation of Treatment With P2Y12 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 clopidogrel prasugrel ticagrelor P2Y12 inhibitors Non-ST-segment elevation acute coronary syndrome network meta-analysis |
| title | Early vs. Delayed Initiation of Treatment With P2Y12 Inhibitors in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials |
| title_full | Early vs. Delayed Initiation of Treatment With P2Y12 Inhibitors in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials |
| title_fullStr | Early vs. Delayed Initiation of Treatment With P2Y12 Inhibitors in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials |
| title_full_unstemmed | Early vs. Delayed Initiation of Treatment With P2Y12 Inhibitors in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials |
| title_short | Early vs. Delayed Initiation of Treatment With P2Y12 Inhibitors in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials |
| title_sort | early vs delayed initiation of treatment with p2y12 inhibitors in patients with non st segment elevation acute coronary syndrome a systematic review and network meta analysis of randomized controlled trials |
| topic | clopidogrel prasugrel ticagrelor P2Y12 inhibitors Non-ST-segment elevation acute coronary syndrome network meta-analysis |
| url | https://www.frontiersin.org/articles/10.3389/fcvm.2022.862452/full |
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