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Guided vs. Standard Antiplatelet Therapy in PCI Patients
Quick Takes
- Compared with standard antiplatelet therapy, the use of platelet function testing or genetic testing to guide antiplatelet therapy in patients undergoing PCI reduced the risk of MACE.
- In addition to the composite ischemic MACE outcome, individual outcomes, including cardiovascular death, MI, stent thrombosis, and stroke, were also reduced.
- These observations provide some support for the use of guided antiplatelet therapy in patients undergoing PCI, but the absence of patient-level data and high degree of heterogeneity among studies for some of the outcomes should be noted.
Study Questions:
What is the safety and efficacy of guided versus standard selection of antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI)?
Methods:
The investigators searched MEDLINE (via PubMed), Cochrane, Embase, and Web of Science databases for randomized controlled trials and observational studies published in any language that compared guided antiplatelet therapy, by means of platelet function testing or genetic testing, versus standard antiplatelet therapy in patients undergoing PCI from August 20–October 25, 2020, for this systematic review and meta-analysis. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. Risk ratios (RRs) and 95% confidence intervals (CIs) were used with random-effects or fixed-effect models according to the estimated heterogeneity among studies assessed by the I2 index. Coprimary endpoints were trial-defined primary major adverse cardiovascular events (MACE) and any bleeding. Key secondary endpoints were all-cause death, cardiovascular death, myocardial infarction (MI), stroke, definite or probable stent thrombosis, and major and minor bleeding. This study is registered with PROSPERO (CRD42021215901).
Results:
A total of 3,656 potentially relevant articles were screened. The analysis included 11 randomized controlled trials and three observational studies with data for 20,743 patients. Compared with standard therapy, guided selection of antiplatelet therapy was associated with a reduction in MACE (RR, 0.78; 95% CI, 0.63–0.95; p = 0.015) and reduced bleeding, although not statistically significant (RR, 0.88; 0.77–1.01; p = 0.069). Cardiovascular death (RR, 0.77; 95% CI, 0.59–1.00; p = 0.049), MI (RR, 0.76; 0.60–0.96; p = 0.021), stent thrombosis (RR, 0.64; 0.46–0.89; p = 0.011), stroke (RR, 0.66; 0.48–0.91; p = 0.010), and minor bleeding (RR, 0.78; 0.67–0.92; p = 0.0030) were reduced with guided therapy compared with standard therapy. Risks of all-cause death and major bleeding did not differ between guided and standard approaches. Outcomes varied according to the strategy used, with an escalation approach associated with a significant reduction in ischemic events without any trade-off in safety, and a de-escalation approach associated with a significant reduction in bleeding, without any trade-off in efficacy.
Conclusions:
The authors concluded that guided antiplatelet therapy improved both composite and individual efficacy outcomes with a favorable safety profile, driven by a reduction in minor bleeding.
Perspective:
This meta-analysis reports that, compared with standard antiplatelet therapy, the use of platelet function testing or genetic testing to guide antiplatelet therapy in patients undergoing PCI reduced the risk of MACE. In addition to the composite ischemic MACE outcome, individual outcomes, including cardiovascular death, MI, stent thrombosis, and stroke, were also reduced. Guided selection of therapy was also associated with a nonsignificant reduction in the endpoint of any bleeding, driven by a reduction in minor bleeding. These observations provide some support for the use of guided antiplatelet therapy in patients undergoing PCI, but the absence of patient-level data and high degree of heterogeneity among studies for some of the outcomes should be noted. Definitive evidence would need a prospective randomized clinical trial.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Prevention, Interventions and ACS
Keywords: Acute Coronary Syndrome, Genetic Testing, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Platelet Function Tests, Primary Prevention, Stents, Stroke, Thrombosis, Vascular Diseases
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