De-escalation versus standard dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis

Switching from a potent P2Y₁₂ blocker to clopidogrel is not uncommon for antiplatelet therapy in patients undergoing percutaneous coronary intervention. This meta-analysis aimed to investigate the efficacy and safety of this de-escalation strategy. Medical literature databases were searched for analysis comparing continued potent antiplatelet therapy and switching to clopidogrel with no language restrictions from inception to 07/May/2018. The primary endpoints of major adverse cardiovascular events (MACE) and major bleeding together with additional efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. A total of 17 896 patients in 13 studies were eligible for analysis, while 17 579 (98.2%) patients presented as acute coronary syndrome and 4105 (23%) patients received the de-escalation therapy. Incidence of MACE was virtually identical in both de-escalation and standard potent antiplatelet therapy groups (odds ratio 0.91, 95% CI 0.73–1.14; <i>P</i> = 0.43). Insignificant difference was also observed in major bleeding (0.99, 0.62–1.60; <i>P</i> = 0.97), all-cause death (0.95, 0.61–1.46; <i>P</i> = 0.81), cardiovascular death (0.66, 0.31–1.42; <i>P</i> = 0.29), myocardial infarction (1.12, 0.80–1.58; <i>P</i> = 0.51), stent thrombosis (1.09, 0.50–2.36; <i>P</i> = 0.83), unplanned revascularization (1.09, 0.83–1.41; <i>P</i> = 0.54), and stroke (1.16, 0.62–2.19; <i>P</i> = 0.64). In conclusion, de-escalation of antiplatelet therapy is associated with nonsignificant differences in both ischemic events and major bleeding compared with standard potent antiplatelet therapy in patients undergoing percutaneous coronary intervention. The feasibility and even superiority of this strategy need to be elucidated by further randomized trials.

对于接受经皮冠状动脉介入治疗（percutaneous coronary intervention）的患者，将强效P2Y₁₂受体拮抗剂（P2Y₁₂ blocker）换用为氯吡格雷（clopidogrel），在抗血小板治疗（antiplatelet therapy）中并非少见的临床策略。本荟萃分析（meta-analysis）旨在探讨此种降阶梯治疗策略（de-escalation strategy）的有效性与安全性。本研究检索了自建库至2018年5月7日、无语言限制的医学文献数据库，纳入对比持续强效抗血小板治疗与换用氯吡格雷方案的研究进行分析。以主要不良心血管事件（major adverse cardiovascular events, MACE）与大出血为主要终点，同时评估多项额外疗效结局，采用随机效应与固定效应模型开展荟萃分析。最终纳入13项研究、共计17896例患者，其中17579例（98.2%）为急性冠脉综合征患者，4105例（23%）接受了降阶梯治疗。降阶梯治疗组与标准强效抗血小板治疗组的主要不良心血管事件发生率几乎一致（比值比0.91，95%置信区间0.73~1.14；P=0.43）。两组在大出血（比值比0.99，95%置信区间0.62~1.60；P=0.97）、全因死亡（比值比0.95，95%置信区间0.61~1.46；P=0.81）、心血管死亡（比值比0.66，95%置信区间0.31~1.42；P=0.29）、心肌梗死（比值比1.12，95%置信区间0.80~1.58；P=0.51）、支架血栓形成（比值比1.09，95%置信区间0.50~2.36；P=0.83）、计划外血运重建（比值比1.09，95%置信区间0.83~1.41；P=0.54）及卒中（比值比1.16，95%置信区间0.62~2.19；P=0.64）方面均无显著差异。综上，对于接受经皮冠状动脉介入治疗的患者，相较于标准强效抗血小板治疗，采用抗血小板治疗降阶梯策略，其缺血事件与大出血发生率均无显著差异。该策略的可行性乃至潜在优越性，尚需进一步的随机对照试验予以阐明。