Net clinical benefit of dual antiplatelet therapy in elderly patients with acute coronary syndrome: A systematic review and meta-analysis
Tomohiro Fujisaki MD
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
Toshiki Kuno and Shun Kohsaka contributed equally as co-senior authors.
Search for more papers by this authorCorresponding Author
Toshiki Kuno MD, PhD
Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
Toshiki Kuno and Shun Kohsaka contributed equally as co-senior authors.
Correspondence Toshiki Kuno, MD, PhD, FESC, FSCAI, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th St, Bronx, New York, NY 10467-2401, USA.
Email: [email protected]
Search for more papers by this authorMasao Iwagami MD, PhD
Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
Search for more papers by this authorYoshihisa Miyamoto MD
Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorHisato Takagi MD, PhD
Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
Search for more papers by this authorPierre Deharo MD
Département de Cardiologie, CHU Timone, Marseille, France
Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
Faculté de Médecine, Aix-Marseille Université, Marseille, France
Search for more papers by this authorThomas Cuisset MD
Département de Cardiologie, CHU Timone, Marseille, France
Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
Faculté de Médecine, Aix-Marseille Université, Marseille, France
Search for more papers by this authorAlexandros Briasoulis MD, PhD
Division of Cardiovascular Medicine, University of Iowa, Iowa, Iowa, USA
Search for more papers by this authorSidakpal Panaich MD
Division of Cardiovascular Medicine, University of Iowa, Iowa, Iowa, USA
Search for more papers by this authorAzeem Latib MD
Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
Search for more papers by this authorShun Kohsaka MD, PhD
Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
Toshiki Kuno and Shun Kohsaka contributed equally as co-senior authors.
Search for more papers by this authorTomohiro Fujisaki MD
Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
Toshiki Kuno and Shun Kohsaka contributed equally as co-senior authors.
Search for more papers by this authorCorresponding Author
Toshiki Kuno MD, PhD
Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, New York, USA
Toshiki Kuno and Shun Kohsaka contributed equally as co-senior authors.
Correspondence Toshiki Kuno, MD, PhD, FESC, FSCAI, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th St, Bronx, New York, NY 10467-2401, USA.
Email: [email protected]
Search for more papers by this authorMasao Iwagami MD, PhD
Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
Search for more papers by this authorYoshihisa Miyamoto MD
Division of Nephrology and Endocrinology, The University of Tokyo, Tokyo, Japan
Search for more papers by this authorHisato Takagi MD, PhD
Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
Search for more papers by this authorPierre Deharo MD
Département de Cardiologie, CHU Timone, Marseille, France
Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
Faculté de Médecine, Aix-Marseille Université, Marseille, France
Search for more papers by this authorThomas Cuisset MD
Département de Cardiologie, CHU Timone, Marseille, France
Center for CardioVascular and Nutrition Research, Aix Marseille Université, Inserm, Inra, Marseille, France
Faculté de Médecine, Aix-Marseille Université, Marseille, France
Search for more papers by this authorAlexandros Briasoulis MD, PhD
Division of Cardiovascular Medicine, University of Iowa, Iowa, Iowa, USA
Search for more papers by this authorSidakpal Panaich MD
Division of Cardiovascular Medicine, University of Iowa, Iowa, Iowa, USA
Search for more papers by this authorAzeem Latib MD
Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
Search for more papers by this authorShun Kohsaka MD, PhD
Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
Toshiki Kuno and Shun Kohsaka contributed equally as co-senior authors.
Search for more papers by this authorAbstract
Background
Contemporary dual antiplatelet therapy (DAPT) strategies, such as short-term DAPT or de-escalation of DAPT, have emerged as attractive strategies to treat patients with acute coronary syndrome (ACS). However, it remains uncertain whether they are suitable for elderly patients.
Methods
PubMed, Embase, and Cochrane CENTRAL databases were searched in September 2022. Randomized controlled trials (RCTs) investigating DAPT strategies, including standard (12 months), short-term, uniform de-escalation, and guided-selection strategies for elderly patients with ACS (age ≥ 65 years) were identified, and a network meta-analysis was conducted. The primary endpoint was the net clinical benefit outcome, a composite of major adverse cardiovascular events (MACEs: cardiovascular death, myocardial infarction, or stroke) and clinically relevant bleeding (equivalent to bleeding of at least type 2 according to the Bleeding Academic Research Consortium). The secondary outcomes were MACE and major bleeding.
Results
Sixteen RCTs with a combined total of 47,911 patients were included. The uniform de-escalation strategy was associated with an improved net clinical benefit compared with DAPT using potent P2Y12 inhibitors. The short-term DAPT strategy was associated with reduced risks of the primary outcome and major bleeding compared with DAPT using potent P2Y12 inhibitors, however, it was ranked as the least effective strategy for MACE compared with other DAPT strategies.
Conclusions
Uniform de-escalation and short-term DAPT strategies may be advantageous for elderly patients, but need to be tailored based on individual bleeding and ischemic risks. Further RCTs of contemporary DAPT strategies specifically designed for elderly patients are warranted to confirm the findings of the present study.
CONFLICT OF INTEREST STATEMENT
Dr. Azeem Latib is a consultant for and on the advisory board of Medtronic, Abbott, Boston Scientific, and Philips. Dr. Shun Kohsaka received an unrestricted research grant from Daiichi Sankyo. All the other authors report that they have no relevant relationships to disclose.
Supporting Information
| Filename | Description |
|---|---|
| ccd30811-sup-0001-CCI_Supplemental_material_0617_without_a_record_of_revision.docx4.4 MB | Supporting information. |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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