Study Finds New Evidence on Personalized Selection of Antiplatelet Therapy

The guidelines recommend the use of P2Y12 inhibitors than clopidogrel to reduce ischemic events in ACS patients. However, this comes at the cost of increased bleeding. Comprehensive comparative analysis that provides safety and efficacy of currently recommended oral P2Y12 inhibitor strategies, including a guided selection approach using platelet function or genetic testing may provide important insights on the best treatment to be used in the specific setting of ACS. Therefore, Dr Mattia Galli and his team conducted a study to evaluate the comparative safety and efficacy of guided vs routine selection of potent P2Y12 inhibiting therapy in patients with ACS.

In a network meta-analysis, the researchers included 61,898 patients from 15 randomized trials that compared different oral P2Y12 inhibitors for the treatment of ACS using either a guided or standard selection approach. They determined clopidogrel as a reference treatment. The major efficacy endpoint assessed was the incidence of major adverse cardiovascular events (MACE) and the major safety endpoint was the incidence of all bleeding.

Key findings of the study:

• Over a mean follow up of 11.9 months, the researchers found that only individualized treatment was associated with a reduction in MACE (incidence rate ratio [IRR] 0.80) without any increase in bleeding (IRR 1.22).
• They noted both a guided approach and prescribing prasugrel led to a decrease in myocardial infarction, while a guided approach and prescribing either prasugrel or ticagrelor were all linked with reduced stent thrombosis.
• They observed that total and cardiovascular mortality were lower with ticagrelor.
• However, they noted that prasugrel was associated with increased major bleeding and minor bleeding went up with both prasugrel and ticagrelor.

The authors concluded, "In patients with an ACS, compared with a routine selection of potent P2Y12 inhibiting therapy (prasugrel or ticagrelor), a guided selection of P2Y12 inhibiting therapy is associated with the most favourable balance between safety and efficacy. These findings support broader adoption of guided approach for the selection of P2Y12 inhibiting therapy in patients with ACS."

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DOI: https://doi.org/10.1093/eurheartj/ehab836