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Antiplatelet Therapy for Secondary Prevention of Coronary Events
Quick Takes
- Findings from this meta-analysis of patient-level data from seven randomized trials showed that among patients with established CAD, P2Y12 inhibition is associated with improved cardiovascular outcomes (mainly reduction in MI rates) compared to aspirin therapy over 2 years.
- There was no significant difference in major bleeding. In fact, P2Y12 inhibition was associated with significantly lower rates of hemorrhagic stroke, stent thrombosis, and any GI bleeding compared to aspirin.
- The treatment effect was consistent across types of P2Y12 inhibitor.
Study Questions:
Is P2Y12 inhibitor monotherapy associated with better clinical outcomes when compared to aspirin in patients with known coronary artery disease (CAD)?
Methods:
This was a patient-level meta-analysis of randomized trials comparing P2Y12 inhibitor monotherapy to aspirin monotherapy for the prevention of cardiovascular events in patients with established CAD. The primary outcome was the composite of cardiovascular death, myocardial infarction (MI), and stroke. Prespecified key secondary outcomes were major bleeding and net adverse clinical events (NACE; the composite of the primary outcome and major bleeding). Data were pooled in a one-step meta-analysis.
Results:
Patient-level data from seven trials included 24,325 participants for analysis, including 12,178 patients assigned to P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 to aspirin. Risk of the primary outcome was lower with P2Y12 inhibitor monotherapy compared with aspirin over 2 years (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.79-0.97; p = 0.012), mainly owing to less MI (HR, 0.77; 95% CI, 0.66-0.90; p < 0.001). Major bleeding was similar (HR, 0.87; 95% CI, 0.70-1.09; p = 0.23) and NACE were lower with P2Y12 inhibitors (HR, 0.89; 95% CI, 0.81-0.98; p = 0.020). The treatment effect was consistent across prespecified subgroups and types of P2Y12 inhibitor.
Conclusions:
Given superior efficacy and similar overall safety, P2Y12 inhibitor monotherapy might be preferred over aspirin monotherapy for long-term secondary prevention in patients with established CAD.
Perspective:
Findings from this meta-analysis of patient-level data from seven randomized trials showed that among patients with established CAD, P2Y12 inhibition is associated with improved cardiovascular outcomes (mainly reduction in MI rates) compared to aspirin therapy. There was no significant difference in major bleeding. In fact, P2Y12 inhibition was associated with significantly lower rates of hemorrhagic stroke, stent thrombosis, and any gastrointestinal (GI) bleeding. These findings challenge existing practice guidelines and may lend support to replacing aspirin monotherapy with P2Y12 inhibitor therapy for secondary prevention of CAD.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease
Keywords: Aspirin, Clopidogrel, Coronary Artery Disease, Gastrointestinal Hemorrhage, Hemorrhage, Myocardial Infarction, Platelet Aggregation Inhibitors, Receptors, Purinergic P2Y12, Secondary Prevention, Stents, Stroke, Thrombosis, Ticagrelor, Vascular Diseases
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