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Meta-Analysis
. 2016 Oct 20:10:3435-3448.
doi: 10.2147/DDDT.S119616. eCollection 2016.

The clinical outcomes of triple antiplatelet therapy versus dual antiplatelet therapy for high-risk patients after coronary stent implantation: a meta-analysis of 11 clinical trials and 9,553 patients

Zhong-Guo Fan  1 , Guo-Bin Ding  2 , Xiao-Bo Li  3 , Xiao-Fei Gao  3 , Ya-Li Gao  1 , Nai-Liang Tian  3
Affiliations
Meta-Analysis

The clinical outcomes of triple antiplatelet therapy versus dual antiplatelet therapy for high-risk patients after coronary stent implantation: a meta-analysis of 11 clinical trials and 9,553 patients

Zhong-Guo Fan et al. Drug Des Devel Ther. .

Abstract

Background: The optimal antiplatelet regimen after in-coronary intervention among patients presenting with complex coronary artery lesions or acute coronary syndrome (ACS) has remained unclear. This study sought to evaluate the clinical outcomes of triple antiplatelet treatment (TAPT) (cilostazol added to aspirin plus clopidogrel) in these patients.

Methods: The PubMed, EMBASE, MEDLINE, and other Internet sources were searched for relevant articles. The primary end point was major adverse cardiac events (MACE), including all-cause mortality, myocardial infarction, and target vessel revascularization. The incidence of definite/probable stent thrombosis and bleeding were analyzed as the safety end points.

Results: Eleven clinical trials involving 9,553 patients were analyzed. The risk of MACE was significantly decreased following TAPT after stent implantation in the ACS subgroup (odds ratio [OR]: 0.72; 95% confidence interval [CI]: 0.61-0.85; P<0.001), which might mainly result from the lower risk of all-cause mortality in this subset (OR: 0.62; 95% CI: 0.48-0.80; P<0.001). The risk of bleeding was not increased with respect to TAPT.

Conclusion: TAPT after stent implantation was associated with feasible benefits on reducing the risk of MACE, especially on reducing the incidence of all-cause mortality among patients suffering from ACS, without higher incidence of bleeding. Larger and more powerful randomized trials are still warranted to prove the superiority of TAPT for such patients.

Keywords: acute coronary syndrome; complex lesions; dual antiplatelet treatment; stent implantation; triple antiplatelet treatment.

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Conflict of interest statement

The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Flow chart depicting the selection of the studies included in this meta-analysis.
Figure 2
Figure 2
The ORs of MACE associated with TAPT compared with DAPT. Notes: Forest plots of the efficacy and safety end points of the included trials. Weights are from random-effects analysis. *Subgroup following propensity score matching. Abbreviations: ACS, acute coronary syndrome; AMI, acute myocardial infarction; CI, confidence interval; COBIS, COronary BIfurcation Stent; DAPT, dual antiplatelet treatment; DECLARE-LONG II, drug-eluting stenting followed by cilostazol treatment reduces late restenosis in patients with long coronary lesions; MACE, major adverse cardiac events; OR, odds ratio; TAPT, triple antiplatelet treatment.
Figure 3
Figure 3
The ORs of all-cause mortality associated with TAPT compared with DAPT. Notes: Forest plots of the efficacy and safety end points of the included trials. *Subgroup following propensity score matching. Abbreviations: ACS, acute coronary syndrome; AMI, acute myocardial infarction; CI, confidence interval; COBIS, COronary BIfurcation Stent; DAPT, dual antiplatelet treatment; DECLARE-LONG II, drug-eluting stenting followed by cilostazol treatment reduces late restenosis in patients with long coronary lesions; OR, odds ratio; TAPT, triple antiplatelet treatment.
Figure 4
Figure 4
The ORs of myocardial infarction associated with TAPT compared with DAPT. Notes: Forest plots of the efficacy and safety end points of the included trials. *Subgroup following propensity score matching. Abbreviations: ACS, acute coronary syndrome; AMI, acute myocardial infarction; CI, confidence interval; COBIS, COronary BIfurcation Stent; DAPT, dual antiplatelet treatment; DECLARE-LONG II, drug-eluting stenting followed by cilostazol treatment reduces late restenosis in patients with long coronary lesions; OR, odds ratio; TAPT, triple antiplatelet treatment.
Figure 5
Figure 5
The ORs of TVR associated with TAPT compared with DAPT. Notes: Forest plots of the efficacy and safety end points of the included trials. Weights are from random-effects analysis. *Subgroup following propensity score matching. Abbreviations: ACS, acute coronary syndrome; AMI, acute myocardial infarction; CI, confidence interval; COBIS, COronary BIfurcation Stent; DAPT, dual antiplatelet treatment; DECLARE-LONG II, drug-eluting stenting followed by cilostazol treatment reduces late restenosis in patients with long coronary lesions; OR, odds ratio; TAPT, triple antiplatelet treatment; TVR, target vessel revascularization.
Figure 6
Figure 6
The ORs of stroke associated with TAPT compared with DAPT. Notes: Forest plots of the efficacy and safety end points of the included trials. *Subgroup following propensity score matching. Abbreviations: ACS, acute coronary syndrome; AMI, acute myocardial infarction; CI, confidence interval; COBIS, COronary BIfurcation Stent; DAPT, dual antiplatelet treatment; DECLARE-LONG II, drug-eluting stenting followed by cilostazol treatment reduces late restenosis in patients with long coronary lesions; OR, odds ratio; TAPT, triple antiplatelet treatment.
Figure 7
Figure 7
The ORs of stent thrombosis associated with TAPT compared with DAPT. Notes: Forest plots of the efficacy and safety end points of the included trials. *Subgroup following propensity score matching. Abbreviations: ACS, acute coronary syndrome; AMI, acute myocardial infarction; CI, confidence interval; COBIS, COronary BIfurcation Stent; DAPT, dual antiplatelet treatment; DECLARE-LONG II, drug-eluting stenting followed by cilostazol treatment reduces late restenosis in patients with long coronary lesions; OR, odds ratio; TAPT, triple antiplatelet treatment.
Figure 8
Figure 8
The ORs of major bleeding associated with TAPT compared with DAPT. Note: Forest plots of the efficacy and safety end points of the included trials. Abbreviations: CI, confidence interval; COBIS, COronary BIfurcation Stent; DAPT, dual antiplatelet treatment; DECLARE-LONG II, drug-eluting stenting followed by cilostazol treatment reduces late restenosis in patients with long coronary lesions; OR, odds ratio; TAPT, triple antiplatelet treatment.
Figure 9
Figure 9
The ORs of minor bleeding associated with TAPT compared with DAPT. Note: Forest plots of the efficacy and safety end points of the included trials. Abbreviations: CI, confidence interval; COBIS, COronary BIfurcation Stent; DAPT, dual antiplatelet treatment; DECLARE-LONG II, drug-eluting stenting followed by cilostazol treatment reduces late restenosis in patients with long coronary lesions; OR, odds ratio; TAPT, triple antiplatelet treatment.
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