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Shoji S, Kuno T, Fujisaki T, et al. De-Escalation of Dual Antiplatelet Therapy in Patients With Acute Coronary Syndromes. J Am Coll Cardiol. 2021 Aug 24;78(8):763-777. doi: 10.1016/j.jacc.2021.06.012. Epub 2021 Jul 15. (Systematic review)
Abstract

BACKGROUND: Balancing the effects of dual antiplatelet therapy (DAPT) in the era of potent P2Y12 inhibitors has become a cornerstone of acute coronary syndrome (ACS) management. Recent randomized controlled trials (RCTs) have investigated DAPT de-escalation to decrease the risk of bleeding outcomes.

OBJECTIVES: The aim of this study was to compare the efficacy and safety outcomes of various DAPT strategies in patients with ACS, including de-escalation from a potent P2Y12 inhibitor to clopidogrel or low-dose prasugrel.

METHODS: MEDLINE and EMBASE were searched through January 2021 for RCTs investigating the efficacy and safety of DAPT in patients with ACS, and a network meta-analysis was conducted. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, and stroke. The primary bleeding outcome was trial-defined major or minor bleeding.

RESULTS: Our search identified 15 eligible RCTs, including 55,798 patients with ACS. De-escalation therapy was associated with reduced risk of primary bleeding outcomes (HR: 0.48 [95% CI: 0.30-0.77] vs clopidogrel; HR: 0.32 [95% CI: 0.20-0.52] vs ticagrelor; HR: 0.36 [95% CI: 0.24-0.55] vs standard-dose prasugrel; and HR: 0.40 [95% CI: 0.22-0.75] vs low-dose prasugrel) without negatively affecting primary efficacy outcomes. There were no significant differences in ischemic or bleeding outcomes between de-escalation to clopidogrel or low-dose prasugrel.

CONCLUSIONS: Compared with other established uses of DAPT, de-escalation was the most effective strategy for ACS treatment, resulting in fewer bleeding events without increasing ischemic events.

Ratings
Discipline Area Score
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Internal Medicine 6 / 7
Cardiology 6 / 7
Comments from MORE raters

General Internal Medicine-Primary Care(US) rater

This is important for several reasons. The most important is bleeding and, of course, efficacy of deescalation. I see patients who are year 2 or 3 post-stent / MI who are still on the more potent antiplatelet meds with not only risk, but the costs are high to acquire the meds.
Comments from EvidenceAlerts subscribers

Dr. Thomas Baitz (9/1/2021 3:18 PM)

How soon was deescalation and why not include single ASA? Why do we still use ECASA? Assessment of deescalation should compare ECASA to clopidogrel.