De-escalation Versus Standard Dual Antiplatelet Therapy In Patients Undergoing Percutaneous Coronary Intervention:A Meta-analysis

Background and objective:Switching from a potent P2Y₁₂2 blocker to the less potent clopidogrel is not uncommon for antiplatelet therapy in patients undergoing percutaneous coronary intervention.This analysis aimed to investigate the efficacy and safety of this de-escalation antiplatelet strategy.Methods:Pubmed,CENTRAL,Embase and Web of Science medical literature databases were searched for relevant randomized controlled trials or observational studies which comparing continued potent antiplatelet therapy and switching to clopidogrel in patients undergoing percutaneous coronary intervention with no language restrictions from inception to 07/May/2018,the references of relevant articles were tracked to prevent omissions.The primary efficacy endpoint was major adverse cardiovascular events,and the primary safety endpoint was major bleeding,additional efficacy endpoints were all-cause death,cardiovascular death,myocardial infarction,stent thrombosis,unplanned revascularization and stroke.These endpoints were assessed by random-effects or fixed-effects models,RevMan 5.3 and Stata 15.1software were used for statistical analysis.Results:A total of 17,896 patients in 13 studies were eligible for analysis,while17579?98.2%?patients presented as acute coronary syndrome and 4105?23%?patients received the de-escalation therapy.Incidence of major adverse cardiovascular events was virtually identical in both de-escalation and standard potent antiplatelet therapy groups?Odds Ratio 0.91,95%Confidence Interval 0.73-1.14;P=0.43?.Insignificant difference was also observed in major bleeding?OR 0.99,95%CI0.62-1.60;P=0.97?,all-cause death?OR 0.95,95%CI 0.61-1.46;P=0.81?,cardiovascular death?OR 0.66,95%CI 0.31-1.42;P=0.29?,myocardial infarction?OR 1.12,95%CI 0.80-1.58;P=0.51?,stent thrombosis?OR 1.09,95%CI 0.50-2.36;P=0.83?,unplanned revascularization?OR 1.09,95%CI 0.83-1.41;P=0.54?and stroke?OR 1.16,95%CI 0.62-2.19;P=0.64?.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.