Efficacy and Safety of Potent Oral P2Y 12 Inhibitors in Medically Managed ACS Patients: a Meta-analysis

Purpose Although current guidelines recommend ticagrelor in addition to aspirin as the antiplatelet strategy for medically managed acute coronary syndrome (MMACS) patients, clinical evidence specific to this special population is lacking. Whether potent oral P2Y 12 inhibitors should be used in MMACS patients is still under debate. Methods We conducted a comprehensive search in PubMed, Embase, Web of Science, and Cochrane Library to identify studies exploring the efficacy or safety of ticagrelor and prasugrel versus clopidogrel or placebo in MMACS patients. The primary efficacy endpoint was major adverse cardiovascular events (MACE) defined by each study, and the safety endpoint was TIMI non-CABG major bleeding. Results A total of 6102 records were screened, and 4 studies including 46,346 patients were finally included. The use of potent oral P2Y 12 inhibitors significantly lowers the risk of MACE compared with clopidogrel (HR: 0.90; 95% CI: 0.82–0.98; P = .018; I 2 = 0%). A significant reduction in risks of all-cause death and myocardial infarction was also observed with the use of potent oral P2Y 12 inhibitors compared with clopidogrel. No significant difference in risks of stroke or TIMI non-CABG major bleeding (HR: 1.24; 95% CI: 0.90–1.73; P = .191; I 2 = 0%) was observed between potent oral P2Y 12 inhibitors and clopidogrel. Conclusion Potent oral P2Y 12 inhibitors, especially ticagrelor, decrease the risk of ischemic events in MMACS patients as compared with clopidogrel, without significantly increasing major bleeding.