P2Y12 Inhibitor or Aspirin Monotherapy for Secondary Prevention of Coronary Events.

Abstract

BACKGROUND:

Aspirin is the only antiplatelet agent with a Class I recommendation for long-term prevention of cardiovascular events in patients with coronary artery disease (CAD). There is inconsistent evidence on how it compares with alternative antiplatelet agents.

OBJECTIVES:

This study compared P2Y12 inhibitor monotherapy vs aspirin in patients with CAD.

METHODS:

We conducted a patient-level meta-analysis of randomized trials comparing P2Y12 inhibitor monotherapy vs aspirin monotherapy for the prevention of cardiovascular events in patients with established CAD. The primary outcome was the composite of cardiovascular death, myocardial infarction, and stroke. Prespecified key secondary outcomes were major bleeding and net adverse clinical events (the composite of the primary outcome and major bleeding). Data were pooled in a 1-step meta-analysis.

RESULTS:

Patient-level data were obtained from 7 trials. Overall, 24,325 participants were available for analysis, including 12,178 patients assigned to receive P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 assigned to receive aspirin. Risk of the primary outcome was lower with P2Y12 inhibitor monotherapy compared with aspirin over 2 years (HR: 0.88; 95% CI: 0.79-0.97; P = 0.012), mainly owing to less myocardial infarction (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 net adverse clinical events were lower (HR: 0.89; 95% CI: 0.81-0.98; P = 0.020) with P2Y12 inhibitors. The treatment effect was consistent across prespecified subgroups and types of P2Y12 inhibitors.

CONCLUSIONS:

Given its 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. (P2Y12 Inhibitor or Aspirin Monotherapy as Secondary Prevention in Patients With Coronary Artery Disease: An Individual Patient Data Meta-Analysis of Randomized Trials [PANTHER collaborative initiative]; CRD42021290774).

• Authors: Felice Gragnano, Davide Cao, Leah Pirondini, Anna Franzone, Hyo-Soo Kim, Moritz von Scheidt, Alf-Åge R Pettersen, Qiang Zhao, Mark Woodward, Mauro Chiarito, Eugene P McFadden, Kyung Woo Park, Adnan Kastrati, Ingebjørg Seljeflot, Yunpeng Zhu, Stephan Windecker, Jeehoon Kang, Heribert Schunkert, Harald Arnesen, Deepak L Bhatt, Philippe Gabriel Steg, Paolo Calabrò, Stuart Pocock, Roxana Mehran, Marco Valgimigli, PANTHER Collaboration
• Journal: Journal of the American College of Cardiology (J Am Coll Cardiol) Vol. 82 Issue 2 Pg. 89-105 (07 11 2023) ISSN: 1558-3597 [Electronic] United States
• PMID: 37407118 (Publication Type: Meta-Analysis, Journal Article, Research Support, Non-U.S. Gov't)
• Copyright: Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Chemical References

• Aspirin
• Purinergic P2Y Receptor Antagonists
• Platelet Aggregation Inhibitors

Topics

• Humans
• Aspirin
• Coronary Artery Disease (drug therapy, prevention & control, chemically induced)
• Secondary Prevention
• Purinergic P2Y Receptor Antagonists
• Platelet Aggregation Inhibitors
• Myocardial Infarction (etiology)
• Hemorrhage (etiology)
• Percutaneous Coronary Intervention (adverse effects)
• Treatment Outcome