RESUMO
BACKGROUND: Debates persist regarding the optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in coronary artery disease (CAD). Recent trials have introduced a novel approach involving P2Y12 inhibitor monotherapy with ticagrelor or clopidogrel, after a short DAPT. However, the effectiveness and safety of this strategy remains to be established. We aimed to perform a meta-analysis comparing monotherapy with P2Y12 inhibitors versus standard DAPT in patients undergoing PCI at 12 months. METHODS: Multiple databases were searched. Six RCTs with a total of 24877 patients were included. The primary endpoint was all-cause mortality at 12 months of follow-up. The secondary endpoints were cardiovascular mortality, myocardial infarction, probable or definite stent thrombosis, stroke events, and major bleeding. The study is registered with PROSPERO (CRD42024499529). RESULTS: Monotherapy with P2Y12 inhibitor ticagrelor significantly reduced both allcause mortality (HR 0.71, 95 CI [0.55-0.91], P = 0.007) and cardiovascular mortality (HR 0.66, 95% CI [0.49-0.89], P = 0.006) compared to standard DAPT. In contrast, clopidogrel monotherapy did not demonstrate a similar reduction. The decrease in mortality associated with ticagrelor was primarily due to a lower risk of major bleeding (HR 0.56, 95% CI [0.43-0.72], P < 0.001), while the risk of myocardial infarction (MI) remained unchanged (HR 0.90, 95% CI [0.73-1.11], P = 0.32). The risk of stroke was found to be similar across treatments. CONCLUSIONS: In comparison to standard DAPT, P2Y12 inhibitor monotherapy with ticagrelor may lead to a reduced mortality. The clinical benefits are driven by a reduction of bleeding risk without ischemic risk trade-off.
Assuntos
Doença da Artéria Coronariana , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária , Antagonistas do Receptor Purinérgico P2Y , Ensaios Clínicos Controlados Aleatórios como Assunto , Humanos , Intervenção Coronária Percutânea/métodos , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Inibidores da Agregação Plaquetária/uso terapêutico , Resultado do Tratamento , Terapia Antiplaquetária Dupla/métodos , Ticagrelor/uso terapêuticoRESUMO
BACKGROUND: Early administration of P2Y12-receptor inhibitors is recommended in all patients with acute coronary syndrome undergoing invasive management, with the aim to achieve the fastest and most effective platelet inhibition. Several trials investigated alternative methods of P2Y12-receptor inhibitor administration (mainly chewed or crushed) aimed at ensuring faster and higher platelet inhibition. Thus, we decided to perform a systematic review and meta-analysis analyzing efficacy and safety of alternative P2Y12-receptor inhibitor administration strategies. METHODS: Systematic research was performed on Pubmed, Cochrane Library, Biomed Central, and Web of Science databases. We included randomized or observational trials testing at least one P2Y12-receptor inhibitor alternative administration. The primary outcome of the study was the value of the platelet reactivity unit (PRU) at 1 h after drug administration, assessed by VerifyNow P2Y12 test (Accumetrics, Inc., San Diego, CA). Secondary outcomes were adverse bleeding events (safety outcome). RESULTS AND DISCUSSION: Fourteen studies were selected for qualitative analysis. Five studies, all focused on ticagrelor, were selected for quantitative efficacy analyses. These five studies compared the administration of crushed/chewed ticagrelor 180 mg loading dose (LD) with the standard whole tablets LD. The pooled mean difference between the two administrations was -59.24 PRU (95% CI from -30.61 to -87.87 PRU) in favor of the crushed/chewed administration, corresponding to a 25% mean relative PRU reduction between alternative and standard P2Y12-receptor inhibitor administrations at 1 h after drug intake. A similar relationship was found in other studies on alternative administration of clopidogrel and prasugrel, not included in the quantitative analysis.
Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Inibidores da Agregação Plaquetária/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Síndrome Coronariana Aguda/sangue , Administração Oral , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Inibidores da Agregação Plaquetária/efeitos adversos , Cloridrato de Prasugrel/administração & dosagem , Cloridrato de Prasugrel/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Segurança , Ticagrelor/administração & dosagem , Ticagrelor/efeitos adversos , Resultado do TratamentoAssuntos
Circulação Colateral , Tratamento Conservador , Circulação Coronária , Oclusão Coronária/terapia , Traumatismos Cardíacos/terapia , Hematoma/terapia , Intervenção Coronária Percutânea/efeitos adversos , Idoso , Doença Crônica , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/fisiopatologia , Embolização Terapêutica , Fibrinolíticos/uso terapêutico , Traumatismos Cardíacos/diagnóstico por imagem , Traumatismos Cardíacos/etiologia , Traumatismos Cardíacos/fisiopatologia , Hematoma/diagnóstico por imagem , Hematoma/etiologia , Hematoma/fisiopatologia , Hemodinâmica , Humanos , Masculino , Inibidores da Agregação Plaquetária/uso terapêutico , Fatores de Tempo , Resultado do Tratamento , Conduta ExpectanteAssuntos
Angioplastia Coronária com Balão , Anomalias dos Vasos Coronários/complicações , Infarto do Miocárdio/terapia , Seio Aórtico/anormalidades , Angiografia Coronária , Anomalias dos Vasos Coronários/diagnóstico , Eletrocardiografia , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico , Seio Aórtico/diagnóstico por imagem , Resultado do TratamentoRESUMO
A 65-year-old man with stable angina refractory to medical therapy and with a low-threshold myocardial ischemia at ECG stress testing was referred for coronary angiography. The coronary angiogram showed an ostial subocclusive stenosis of a developed first diagonal branch located just upstream of a subocclusive stenosis of the mid left anterior descending (LAD) coronary artery, occluded distally, and a coronary collateral for LAD from a developed right ventricular branch arising with separate ostia from the right sinus of Valsalva. We discuss the diagnostic interpretation of this coronary anomaly and some aspects regarding the percutaneous treatment of bifurcations.
Assuntos
Circulação Colateral , Circulação Coronária , Estenose Coronária/complicações , Anomalias dos Vasos Coronários/complicações , Idoso , Angiografia Coronária , Estenose Coronária/diagnóstico por imagem , Anomalias dos Vasos Coronários/diagnóstico por imagem , Humanos , MasculinoRESUMO
Anomalies of the coronary artery are incidentally detected during coronary angiography and are seldom found in daily clinical practice. In the reported studies, the incidence ranges from 0.6 to 1.3%, and men are more frequently affected. Among the different types, the detection of a double left anterior descending coronary artery emerging from the right coronary sinus is extremely rare. We describe a case of a 64-year-old male patient admitted to our institution because of ST segment elevation myocardial infarction. After successful systemic lysis, he underwent coronary angiography that showed multivessel coronary disease, a patent infarct-related artery and a double left anterior descending artery. We discuss the clinical relevance of a coronary artery emerging from the opposite Valsalva sinus and its clinical implications.