Coronary disease & ACSMeta-analysis
Ticagrelor or Clopidogrel Monotherapy vs Dual Antiplatelet Therapy After Percutaneous Coronary Intervention
- Systematic review and individual participant data meta-analysis of randomised trials
- 1-step mixed-effects model
- noninferiority
- per-protocol analysis
Authors' conclusion
This systematic review and meta-analysis found that ticagrelor monotherapy was noninferior to DAPT for all-cause death, MI, or stroke and superior for major bleeding and NACE. Clopidogrel monotherapy was similarly associated with reduced bleeding but was not noninferior to DAPT for all-cause death, MI, or stroke, largely because of risk observed in 1 trial that exclusively included East Asian patients and a hazard that was driven by an excess of noncardiovascular death.
Study context
- Population
- Patients undergoing percutaneous coronary intervention (PCI) without indication to oral anticoagulation
- Participants
- 25,960 patients · 6 RCTs
- Comparison
- Ticagrelor or clopidogrel monotherapy vs dual antiplatelet therapy (DAPT) after PCI
- Ticagrelorn = 8,292
- Clopidogreln = 3,654
- DAPTn = 12,403reference
- Outcome
- Death, myocardial infarction (MI) or stroke (noninferiority, HR margin 1.15, per-protocol)
Pooled result
As reported in the abstract
Death, MI or stroke
Each group vs DAPTHazard ratio (95% CI)P value
Ticagrelornoninferior
0.89(0.74–1.06)
P = 0.004for non-inferiorityClopidogrelnot noninferior; driven by noncardiovascular death
1.37(1.01–1.87)
P > 0.99for non-inferiorityFurther pooled results
| Outcome | HR (95% CI) | P value | |
|---|---|---|---|
| NACE (primary end point and major bleeding) — Ticagrelor vs DAPT | 0.74 (0.64–0.86) | P < 0.001 | |
| NACE (primary end point and major bleeding) — Clopidogrel vs DAPT | 1.00 (0.78–1.28) | P = 0.99 | |
| 0.512Hazard ratio (log scale) |
- Net adverse clinical events (NACE) (primary end point and major bleeding): P for interaction = .04
Safety
| Outcome | HR (95% CI) | P value | |
|---|---|---|---|
| Major bleeding — Ticagrelor vs DAPT | 0.47 (0.36–0.62) | P < 0.001 | |
| Major bleeding — Clopidogrel vs DAPT | 0.49 (0.30–0.81) | P = 0.006 | |
| 0.20.5125Hazard ratio (log scale) |
- Major bleeding: P for interaction = 0.88
Original publication
Ticagrelor or Clopidogrel Monotherapy vs Dual Antiplatelet Therapy After Percutaneous Coronary Intervention. JAMA Cardiol. Published 1 May 2024. doi:10.1001/jamacardio.2024.0133
Summarised from the published abstract; every number is checked against it