De-escalating dual antiaggregation could be the most effective strategy after acute coronary syndrome seeing as it prevents bleeding and cut down costs with no increase of ischemic events.
Balancing the effects of dual antiaggregation therapy (DAPT) in the era of potent P2Y12 inhibitors has become the cornerstone of acute coronary syndrome (ACS) management.
This meta-analysis included 15 randomized studies with over 55,000 patients comparing safety and efficacy of DAPT in ACS, including de-escalating a potent inhibitor to clopidogrel or low doses of prasugrel.
Primary efficacy end point was a combination of cardiovascular death, MI and stroke. Safety end point evidently was bleeding, both minor and major.
De-escalating was associated to significant reduction in bleeding (HR: 0.48 vs clopidogrel; HR: 0.32 vs ticagrelor; HR: 0.36 vs standard prasugrel dose and HR: 0.40 vs low prasugrel dose). There was no ischemic compromise.
There were no significant differences in ischemic or bleeding events between de-escalating to clopidogrel vs prasugrel.
Conclusion
De-escalating to clopidogrel or low doses of prasugrel resulted the most effective strategy, reducing bleeding and with no ischemic compromise, vs other established DAPT strategies with potent P2Y12 inhibitors.
Original Title: De-Escalation of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndromes.
Reference: Satoshi Shoji et al. J Am Coll Cardiol. 2021 Jul 9;S0735-1097(21)05327-4. Online ahead of print. doi: 10.1016/j.jacc.2021.06.012.
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