Efficacy And Safety Of Different Antiplatelet Therapy Regimens In Patients With Acute Coronary Syndrome Undergone Percutaneous Coronary Intervention:A Network Meta-Analysis

Objective:Dual antiplatelet therapy(DAPT)based on potent P2Y12 inhibitor is the cornerstone of acute coronary syndrome(ACS)management.Balancing the effects of different strategies of antiplatelet therapy after percutaneous coronary intervention(PCI)including DAPT de-escalation,potent P2Y12 inhibitor monotherapy,and conventional DAPT is a hot topic.Methods:A systematic search was produced from the MEDLINE,PubMed,CNKI,Wanfang database,and Embase through October 2021 to identify different DAPT strategies in randomized controlled trials(RCTs)for treatment of ACS patients after undergoing PCI with drug-eluting stent(DES).The network meta-analysis was performed to investigate the net clinic benefit of the DAPT de-escalation,potent P2Y12 inhibitor monotherapy,as well as conventional DAPT.The primary outcome was defined as net adverse clinical events,concluded as a composite of major bleeding and cardiac death,myocardial infarction,stroke,stent thrombosis or target-vessel revascularization.The efficacy outcome events were defined as major cardiovascular adverse events(MACE),including cardiac death,recurrent myocardial infarction,stent thrombosis,stroke,or target vessel revascularization.The safety outcome events included thrombolysis in myocardial infarction(TIMI)major or minor bleeding events.RevMan 5.3 software was used to evaluate literature quality,and the "mvmeta" package of STATA 14.0 software was used to calculate odds ratio(OR)and 95% confidence interval(CI)to represent the pooled effect size.P < 0.05 indicated statistically significant difference.Results:A total of 14 RCTs with 63,982 patients were included.The DAPT de-escalation was associated with a lower risk of the primary outcome compared with potent P2Y12 inhibitor monotherapy(De-escalation vs monotherapy OR: 0.72 95% CI:0.55–0.96),and other antiplatelet strategies(De-escalation vs clopidogrel + aspirin OR: 0.49 95% CI: 0.39–0.63;De-escalation vs prasugrel + aspirin OR: 0.76 95% CI:0.59–0.98;De-escalation vs ticagrelor + aspirin OR: 0.76 95% CI: 0.55–0.90).There were no statistical differences in the incidence of bleeding(DAPT de-escalation vs P2Y12 inhibitor monotherapy OR: 0.73 95% CI: 0.47–1.12)and major adverse cardiac events(DAPT de-escalation vs P2Y12 inhibitor monotherapy OR: 0.79 95%CI: 0.59–1.08)between DAPT de-escalation and potent P2Y12 inhibitor monotherapy.The potent P2Y12 inhibitor monotherapy also had a significant advantage in net clinical benefit over conventional DAPT strategies(vs clopidogrel + aspirin OR:0.6895%CI: 0.44-0.86;vs prasugrel + aspirin OR:0.76 95%CI:0.59-0.98;vs ticagrelor +aspirin OR:0.76 95%CI:0.65-0.90).Conclusions:This network meta-analysis showed that among patients with ACS treated with PCI,DAPT de-escalation and potent P2Y12 receptor antagonists can both reduce net adverse events compared with conventional DAPT regiments,mainly derived from the reduced risk of bleeding.DAPT de-escalation was associated with more clinical benefits than potent P2Y12 receptor antagonists.