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. 2023 May 1;50(3):e227916.
doi: 10.14503/THIJ-22-7916.

P2Y12 Inhibitors for Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis

Tomohiro Fujisaki  1   2   3 , Toshiki Kuno  4   5 , Alexandros Briasoulis  6 , Naoki Misumida  7 , Hisato Takagi  8 , Azeem Latib  5
Affiliations

P2Y12 Inhibitors for Non-ST-Segment Elevation Acute Coronary Syndrome: A Systematic Review and Network Meta-Analysis

Tomohiro Fujisaki et al. Tex Heart Inst J. .

Abstract

Background: For patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), prasugrel was recommended over ticagrelor in a recent randomized controlled trial, although more data are needed on the rationale. Here, the effects of P2Y12 inhibitors on ischemic and bleeding events in patients with NSTE-ACS were investigated.

Methods: Clinical trials that enrolled patients with NSTE-ACS were included, relevant data were extracted, and a network meta-analysis was performed.

Results: This study included 37,268 patients with NSTE-ACS from 11 studies. There was no significant difference between prasugrel and ticagrelor for any end point, although prasugrel had a higher likelihood of event reduction than ticagrelor for all end points except cardiovascular death. Compared with clopidogrel, prasugrel was associated with decreased risks of major adverse cardiovascular events (MACE) (hazard ratio [HR], 0.84; 95% CI, 0.71-0.99) and myocardial infarction (HR, 0.82; 95% CI, 0.68-0.99) but not an increased risk of major bleeding (HR, 1.30; 95% CI, 0.97-1.74). Similarly, compared with clopidogrel, ticagrelor was associated with a reduced risk of cardiovascular death (HR, 0.79; 95% CI, 0.66-0.94) and an increased risk of major bleeding (HR, 1.33; 95% CI, 1.00-1.77; P = .049). For the primary efficacy end point (MACE), prasugrel showed the highest likelihood of event reduction (P = .97) and was superior to ticagrelor (P = .29) and clopidogrel (P = .24).

Conclusion: Prasugrel and ticagrelor had comparable risks for every end point, although prasugrel had the highest probability of being the best treatment for reducing the primary efficacy end point. This study highlights the need for further studies to investigate optimal P2Y12 inhibitor selection in patients with NSTE-ACS.

Keywords: Non-ST elevated myocardial infarction; acute coronary syndrome; prasugrel hydrochloride; purinergic P2Y receptor antagonists; ticagrelor.

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Conflict of interest statement

Conflict of Interest/Disclosure: Dr Latib is a consultant and on the advisory board of Medtronic, Abbott, Boston Scientific, and Philips. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

Fig. 1.
Fig. 1.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the study selection process.
Fig. 2.
Fig. 2.
Network meta-analysis of MACE (random-effects model). The figure presents each treatment arm's hazard ratio and 95% CI. A) Network plot of P2Y12 inhibitor regimens. B) Forest plot comparing other inhibitors with ticagrelor, showing no significant difference between other inhibitors and ticagrelor. C) Forest plot comparing other inhibitors and prasugrel. D) Forest plot comparing other inhibitors with clopidogrel, showing that prasugrel is associated with a decreased risk of MACE vs clopidogrel. HR, hazard ratio; MACE, major adverse cardiac events.
Fig. 3.
Fig. 3.
Network meta-analysis of major bleeding (random-effects model). The figure presents each treatment arm's HR and 95% CI. A) Network plot of P2Y12 inhibitor regimens. Forest plots comparing B) other inhibitor with ticagrelor, C) other inhibitor with prasugrel, and D) other inhibitor with clopidogrel show that ticagrelor is associated with an increased risk of major bleeding compared with clopidogrel (P = .049). HR, hazard ratio.
See this image and copyright information in PMC

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