Abstract
De-escalation from ticagrelor to clopidogrel in acute coronary syndrome (ACS) may occur for a variety of reasons, including side effects (bleeding and non-bleeding) and costs. This study sought to assess the prevalence of de-escalation from ticagrelor to clopidogrel and the occurrence of adverse clinical outcomes following de-escalation. We conducted a systematic review of clinical trials and real-world studies in ACS patients treated with ticagrelor. Real-world data on the prevalence of de-escalation during hospitalization or at discharge, after hospital discharge, and during the whole study period were included for meta-analysis. Major adverse cardiovascular events (MACE) and bleeding events occurring after de-escalation were also assessed. A total of 12 studies were eligible for meta-analysis of the prevalence of de-escalation. De-escalation from ticagrelor to clopidogrel therapy occurred with a mean prevalence of 19.8% [95% confidence interval (CI) 11.2–28.4%]. De-escalation occurred more frequently in-hospital or at discharge than after hospital discharge (23.7% vs. 15.8%). For assessment of clinical outcomes, a total of six studies were eligible for meta-analysis. Mean rate of MACE for patients with de-escalation was 2.1% (95% CI 1.1–4.1%) and the rate of major bleeding events was 1.3% (95% CI 0.4–4.5%). In conclusion, de-escalation commonly occurs in real-world practice. Although rates of major cardiovascular and bleeding events in this analysis were generally low, the profile of patients suitable for de-escalation, the impact of de-escalation on adverse clinical outcomes and how this is affected by the timing after index ACS warrants further large-scale investigation.
Highlights
Materials and methodsCurrent U.S and European guidelines recommend dual antiplatelet therapy (DAPT) with aspirin plus a P 2Y12 receptor inhibitor in patients with acute coronary syndrome (ACS) [1,2,3]
When analyzing the safety and efficacy of de-escalation (574 patients analyzed), results of the meta-analysis showed the rate of Major adverse cardiovascular events (MACE) was 2.1% during a mean follow-up duration of 10 months and with no observed heterogeneity (Fig. 2a)
In the absence of large observational studies or randomized clinical trials assessing this modality of de-escalation, the current study aimed to pool the relevant studies to offer insights into treatment patterns in the real-world and the clinical implications associated with such practice
Summary
Current U.S and European guidelines recommend dual antiplatelet therapy (DAPT) with aspirin plus a P 2Y12 receptor inhibitor in patients with ACS [1,2,3]. Switching between P2Y12 receptor inhibitors frequently occurs in real-world practice and de-escalation from a more potent to a less potent agent has become part of a stage-adapted therapy [8] In this practice, providers use more potent P2Y12 inhibitors to increase protection from ischemic events in the early phase after ACS, and later switch to clopidogrel to reduce bleeding [9]. Outcomes included the prevalence rate of patients who switched from ticagrelor to clopidogrel, the time to switch or duration of initial ticagrelor therapy, and the reasons for de-escalation. Eligibility criteria for studies on the clinical outcomes associated with de-escalation included clinical trials and observational studies in patients who received initial treatment with ticagrelor and subsequently switched to clopidogrel treatment. All analyses were performed using the R metaphor v2.0.0 package within the DOC Data version 2.0 software platform [24]
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
