Long Term Outcome Of Prasugrel Vs. Clopidogrel In Patients With Acute Coronary Syndrome:A Meta-Analysis

Background There is a general consensus on the recommendation of the duration dual antiplatelet therapy for at least 1 year after DES placement in ACS patients with low bleeding risk. Recent European guidelines favor prasugrel and ticagrelor over clopidogrel, whereas American guidelines consider these options to be possible alternatives. Due to the effect of the clopidogrel on platelet aggregation inhibition is highly variable due to transformation of the prodrug to the active metabolite, the newly developed P2Y12 receptor antagonist, Prasugrel, have been shown to be more potent than clopidogrel by its faster, greater and more consistent effect. However it is not known whether this translates into long term clinical benefit in patients with ACS, and undergoing PCI.Objective The aim of this study is to perform a meta-analysis for systematically reviewing the evidence on the long term (≥lyear) efficacy and safety of novel oral P2Y12 inhibitor prasugrel in comparison to clopidogrel in patients with ACS.Material/Methods After searching electronic database (up to May 2016), six studies were finally included. Pooled risk ratios (RRs) and confidence intervals (CIs) were calculated to assess all causes of death, myocardial infarction (MI), stroke, major bleeding, major/minor bleeding, and stent thrombosis (for PCI performed).Results compared with clopidogrel, prasugrel had similar risks of all causes of death (Pooled RR:0.92; 95%CI:0.82-1.03; P=0.14; I2=40%), MI(Pooled RR:0.82; 95%CI:0.66-1.02; P=0.08; I2=64%),and stroke (Pooled RR:0.85; 95%CI:0.68-1.07; P=0.16; I2=5%).However, prasugrel was associated with significantly higher risk of major Bleeding (Pooled RR:1.21; 95%CI:1.01-1.44; P=0.04; I2=0%). For the patients who underwent percutaneous coronary intervention (PCI), prasugrel was associated with significantly lower risk of stent thrombosis (Pooled RR:0.49; 95%CI:0.37-0.65; P<0.00001;I2=12%).Conclusion Prasugrel has similar effects as clopidogrel in term of all causes of death, MI and stroke in ACS patients. For the patients who underwent PCI, prasugrel contributes to lower risk of stent thrombosis. However, prasugrel is associated with significantly higher risk of bleeding. For the patients with active pathological bleeding or a history of stroke and/or TIA, prasugrel should not be recommended.