scholarly journals Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in Acute Coronary Syndrome: an Updated Meta-Analysis

2021 ◽  
Author(s):  
Mengyi Sun ◽  
Weichen Cui ◽  
Linping Li
Keyword(s):  
Clinical Trials ◽  
Acute Coronary Syndrome ◽  
Clinical Outcomes ◽  
Observational Studies ◽  
Meta Analysis ◽  
Therapeutic Effects ◽  
Minor Bleeding ◽  
Coronary Syndrome ◽  
Risk Of Bleeding ◽  
Significant Difference

Abstract Background: Ticagrelor is currently recommended for patients with acute coronary syndrome (ACS). However, recent studies have yielded controversial results. Objective: To compare the clinical outcomes of ticagrelor and clopidogrel in ACS patients.Methods: Three electronic databases were queried until April 1, 2021. Major adverse cardiovascular event (MACE) was the primary efficacy endpoint. The secondary efficacy endpoints included stroke, stent thrombosis (ST), cardiovascular (CV) death, all-cause death, and myocardial infarction (MI). The safety endpoints were (major and minor) bleeding. Odds ratios (ORs) and 95% confidence intervals (CIs) and were calculated to represent the estimated effect sizes.Results: Nine clinical trials and 18 observational studies with 269,935 ACS patients were included. No significant difference was detected in MACE (OR 0.76, 95% CI 0.54-1.06, p = 0.11, I² = 66.74%), but ticagrelor introduced a higher risk of bleeding (1.49, 1.14-1.94, 0.00, 63.97%) and minor bleeding (1.57, 1.08-2.30, 0.02, 59.09%) in clinical trials. The secondary efficacy endpoints differed between clinical trials and observational studies. Subgroup analysis demonstrated that ticagrelor showed better therapeutic effects in patients underwent PCI (0.38, 0.23-0.63, 0.00, 0) than those intended for PCI (1.02, 0.70-1.49, 0.93, 68.99%). Meanwhile ticagrelor showed different therapeutic effects on ACS patients of different ethnicities and from different countries.Conclusion:This meta-analysis demonstrated that ticagrelor is not superior to clopidogrel in MACE but is associated with a higher risk of bleeding in ACS patients. Different PCI strategies, ethnicities, and countries may be the factors that contribute to different therapeutic efficacy of ticagrelor.

Comparison of prasugrel and ticagrelor for patient with acute coronary syndrome: a systematic review and meta-analysis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L.C.W Fong ◽  
N Lee ◽  
A.T Yan ◽  
M.Y Ng
Keyword(s):  
Acute Coronary Syndrome ◽  
Stent Thrombosis ◽  
Meta Analysis ◽  
Composite Endpoint ◽  
Cardiovascular Death ◽  
Coronary Syndrome ◽  
Primary Composite Endpoint ◽  
Significant Difference ◽  
St Elevation

Abstract Background Prasugrel and ticagrelor are both effective anti-platelet drugs for patients with acute coronary syndrome. However, there has been limited data on the direct comparison of prasugrel and ticagrelor until the recent ISAR-REACT 5 trial. Purpose To compare the efficacy of prasugrel and ticagrelor in patients with acute coronary syndrome with respect to the primary composite endpoint of myocardial infarction (MI), stroke or cardiac cardiovascular death, and secondary endpoints including MI, stroke, cardiovascular death, major bleeding (Bleeding Academic Research Consortium (BARC) type 2 or above), and stent thrombosis within 1 year. Methods Meta-analysis was performed on randomised controlled trials (RCT) up to December 2019 that randomised patients with acute coronary syndrome to either prasugrel or ticagrelor. RCTs were identified from Medline, Embase and ClinicalTrials.gov using Cochrane library CENTRAL by 2 independent reviewers with “prasugrel” and “ticagrelor” as search terms. Effect estimates with confidence intervals were generated using the random effects model by extracting outcome data from the RCTs to compare the primary and secondary clinical outcomes. Cochrane risk-of-bias tool for randomised trials (Ver 2.0) was used for assessment of all eligible RCTs. Results 411 reports were screened, and we identified 11 eligible RCTs with 6098 patients randomised to prasugrel (n=3050) or ticagrelor (n=3048). The included trials had a follow up period ranging from 1 day to 1 year. 330 events on the prasugrel arm and 408 events on the ticagrelor arm were recorded. There were some concerns over the integrity of allocation concealment over 7 trials otherwise risk of other bias was minimal. Patients had a mean age of 61±4 (76% male; 50% with ST elevation MI; 35% with non-ST elevation MI; 15% with unstable angina; 25% with diabetes mellitus; 64% with hypertension; 51% with hyperlipidaemia; 42% smokers). There was no significant difference in risk between the prasugrel group and the ticagrelor group on the primary composite endpoint (Figure 1) (Risk Ratio (RR)=1.17; 95% CI=0.97–1.41; p=0.10, I2=0%). There was no significant difference between the use of prasugrel and ticagrelor with respect to MI (RR=1.24; 95% CI=0.81–1.90; p=0.31); stroke (RR=1.05; 95% CI=0.66–1.67; p=0.84); cardiovascular death (RR=1.01; 95% CI=0.75–1.36; p=0.95); BARC type 2 or above bleeding (RR=1.17; 95% CI =0.90–1.54; p=0.24); stent thrombosis (RR=1.58; 95% CI =0.90–2.76; p=0.11). Conclusion Compared with ticagrelor, prasugrel did not reduce the primary composite endpoint of MI, stroke and cardiovascular death within 1 year. There was also no significant difference in the risk of MI, stroke, cardiovascular death, major bleeding and stent thrombosis respectively. Figure 1. Primary Objective Funding Acknowledgement Type of funding source: None

scholarly journals 68 The impact of the weekend admission on early mortality after acute coronary syndrome: a meta-analysis of observational studies

Heart ◽  
2017 ◽  
Vol 103 (Suppl 5) ◽  
pp. A51-A52
Author(s):  
Chun Shing Kwok ◽  
Mohammed Al-Dokheal ◽  
Sami Aldaham ◽  
Claire Rushton ◽  
Robert Butler ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Observational Studies ◽  
Meta Analysis ◽  
Early Mortality ◽  
Coronary Syndrome ◽  
The Impact

scholarly journals Bleeding Risk in Non-Valvular Atrial Fibrillation Patients Receiving Direct Oral Anticoagulants and Warfarin: A Systematic Review and Meta-Analysis of Observational Studies

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 3672-3672 ◽  
Author(s):  
Yimin Pearl Wang ◽  
Rohan Kehar ◽  
Alla Iansavitchene ◽  
Alejandro Lazo-Langner
Keyword(s):  
Major Bleeding ◽  
Lower Risk ◽  
Observational Studies ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Bleeding Risk ◽  
Risk Of Bleeding ◽  
Significant Difference

Introduction: The standard oral anticoagulant therapy administered to non-valvular AF patients has typically been Vitamin K Antagonists (VKA) particularly warfarin. In recent years, Direct Oral Anticoagulants (DOACs) including Direct Thrombin Inhibitors (DTI) and Direct Factor Xa inhibitors (FXa inhibitors) have become an alternative to warfarin. Randomized trials comparing warfarin and DOACs showed comparable effectiveness without significant additional major bleeding risk. However, bleeding events in RCTs may differ from those in daily use due to the routine exclusion of patients with a higher risk of bleeding from many studies. We aimed to assess bleeding risk between DOACs and warfarin in AF patients in observational studies and we also sought to determine differences between patients that were experienced or naïve to oral anticoagulants. Methods: A systematic literature search was conducted in the OVID MEDLINE® and EMBASE® electronic databases. Observational studies and randomized control trials (RCT) from 1990 to January 2019 were retrieved and examined by two independent reviewers. A pooled effect hazard ratio (HR) was calculated using a random effects model using the generic inverse variance method. Subgroup analyses according to previous exposure to anticoagulants, study type, funding type and DOAC type were conducted. The primary outcome was major bleeding risk. The secondary outcome was clinically relevant non-major bleeding. All studies must have used an established or validated definition of major bleeding. Results: The initial literature search identified 3359 potentially eligible citations. After primary screening, 150 articles were eligible for full text review and there were 35 studies including 2,356,201 patients that met the inclusion criteria. Overall, patients on DOACs were less likely to experience a bleeding event compared to warfarin (HR 0.78, 95%CI 0.71, 0.85, P<0.001). The results were consistent when analyzing patients receiving DTIs or FXa inhibitors (DTI: HR 0.76, 95% CI 0.67,0.87; FXa inhibitors: HR 0.79, 95% CI 0.69,0.89). However, among patients receiving factor Xa inhibitors, there was a significant difference in the risk of bleeding according to individual drug. Among patients receiving rivaroxaban the risk of bleeding was similar to warfarin (HR 0.98, 95%CI 0.91,1.06, p=0.60) whereas in those receiving apixaban there was a 40% reduction in the risk of bleeding compared to warfarin (HR 0.60, 95%CI 0.50,0.71, p<0.001) (Figure 1). Three studies reported information according to previous anticoagulant exposure. The overall pooled hazard ratio was 0.68 (95% CI 0.55, 0.82 p<0.001) in favor of patients on DOACs. In the subgroup analysis of previous anticoagulant use, the risk of bleeding was lower for DOACs compared to warfarin in both the experienced population (HR 0.70, 95%CI 0.51, 0.96) and the naïve population (HR 0.64, 95% CI 0.47,0.87). However, heterogeneity was moderate to high among both subgroups. Conclusion: This review and meta-analysis of observational studies including over 2.3 million patients showed that overall DOACs have a lower risk of major bleeding and clinically relevant non-major bleeding compared to warfarin. Most importantly, although the pooled effect estimate did not differ between DTIs and FXa inhibitors, among patients receiving FXa inhibitors there was a significant difference between individual agents. Patients on apixaban had a significantly lower risk of bleeding compared to warfarin in contrast to patients on rivaroxaban who had a similar risk. Disclosures No relevant conflicts of interest to declare.

scholarly journals The safety of morphine use in acute coronary syndrome: a meta-analysis

Heart Asia ◽  
2019 ◽  
Vol 11 (1) ◽  
pp. e011142 ◽  
Author(s):  
Rugheed Ghadban ◽  
Tariq Enezate ◽  
Joshua Payne ◽  
Haytham Allaham ◽  
Ahmad Halawa ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Major Bleeding ◽  
Pain Control ◽  
Controlled Trial ◽  
Cochrane Central Register ◽  
Minor Bleeding ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Significant Difference ◽  
All Cause Mortality

BackgroundMorphine is widely used for pain control in patients with acute coronary syndrome (ACS). Several studies have questioned the safety of morphine in this setting with a concern of interaction with and reduced efficacy of antiplatelet agents.ObjectiveThis study aims to systematically review the safety of morphine use in ACS.MethodsMEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were queried from inception through April 2018. Studies comparing morphine to nonmorphine use in ACS were included. Study endpoints included: in-hospital myocardial infarction (MI), all-cause mortality, stroke, major bleeding, minor bleeding and dyspnoea.ResultsA total of 64 323 patients with ACS were included from eight studies, seven of which were observational studies and one was a randomised controlled trial. The use of morphine was associated with increased risk of in-hospital recurrent MI (OR 1.30, 95% CI 1.18 to 1.43, p < 0.00001). There was, however, no significant difference in terms of all-cause mortality (OR 0.87, 95% CI 0.62 to 1.22, p = 0.44), stroke (OR 0.81, 95% CI 0.39 to 1.66, p = 0.57), major bleeding (OR 0.49, 95% CI 0.24 to 1.00, p = 0.05), minor bleeding (OR 0.98, 95% CI 0.41 to 2.34, p = 0.97), or dyspnoea (OR 0.55, 95% CI 0.16 to 1.83, p = 0.33).ConclusionThe use of morphine for pain control in ACS was associated with an increased risk of in-hospital recurrent MI. Randomised clinical trials are needed to further investigate the safety of morphine in ACS.

scholarly journals Outcome Differences of Remnant- Preserving versus Non-Preserving Methods in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Meta-analysis with Subgroup analysis

2020 ◽  
Vol 32 (1) ◽  
Author(s):  
Sung Hun Won ◽  
Byung-Il Lee ◽  
Su Yeon Park ◽  
Kyung-Dae Min ◽  
Jun-Bum Kim ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Acl Reconstruction ◽  
Subgroup Analysis ◽  
Observational Studies ◽  
Ligament Reconstruction ◽  
Cruciate Ligament ◽  
Meta Analysis ◽  
Lachman Test ◽  
Significant Difference ◽  
Anterior Cruciate

Abstract Purpose To analyze differences in clinical outcomes of arthroscopic anterior cruciate ligament reconstruction between remnant-preserving and non-preserving methods. Methods International electronical databases PubMed, Embase, and the Cochrane central database from January 1966 to December 2017 were searched for randomized controlled trials (RCTs) and observational studies that compared differences of clinical outcomes of ACL reconstruction with and without remnant preservation. A meta-analysis of these studies was performed to compare clinical outcomes. Subgroup analyses were conducted to evaluate the role of methodological quality in primary meta-analysis estimates. Results Five RCTs and six observational studies were included in this meta-analysis and subgroup analysis. The remnant-preserving method in arthroscopic ACL reconstruction showed a statistically significant difference compared to the non-preserving method regarding arthrometric evaluation (side-to-side difference). Lachman test, Lysholm scores, and IKDC subjective scores showed statistically minor difference in meta-analysis, but showed no significant difference in subgroup analysis. Remained parameters including pivot shift test, IKDC grades, incidence of cyclops lesion showed no statistically differences in meta-analysis or subgroup analysis. Conclusions This meta-analysis with subgroup analysis showed that arthroscopic remnant-preserving ACL reconstruction provided statistically significant but limited clinical relevance in terms of arthrometric evaluation. Results of Lachman test, Lysholm scores, and IKDC subjective scores demonstrated statistically minor differences.

scholarly journals Comparison of platelet reactivity between prasugrel and ticagrelor in patients with acute coronary syndrome: a meta-analysis

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Mingxiang Wen ◽  
Yaqi Li ◽  
Xiang Qu ◽  
Yanyan Zhu ◽  
Lingfang Tian ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Platelet Reactivity ◽  
Weighted Mean Difference ◽  
Meta Analysis ◽  
Reactivity Index ◽  
Cochrane Library ◽  
Coronary Syndrome ◽  
Significant Difference ◽  
Definition Of ◽  
The Cochrane Library

Abstract Background This meta-analysis aimed to compare the effects of prasugrel and ticagrelor on high (HTPR) and low on-treatment platelet reactivity (LTPR) in patients with acute coronary syndrome (ACS). Methods Eligible studies were retrieved from PubMed, Embase, and the Cochrane Library. HTPR and LTPR were evaluated on the basis of the vasodilator-stimulated phosphoprotein platelet reactivity index (VASP-PRI) and P2Y12 reaction units (PRUs). HTPR and LTPR were analyzed using risk ratios (RRs) and their 95% confidence intervals (CIs). Weighted mean difference (WMD) and 95% CI were used to calculate the pooled effect size of platelet reactivity (PR). Results Fourteen eligible studies were obtained, which included 2629 patients treated with ticagrelor (n = 1340) and prasugrel (n = 1289). The pooled results showed that the prasugrel-treated patients had higher platelet reactivity than the ticagrelor-treated patients (PRU: WMD = − 32.26; 95% CI: − 56.48 to − 8.76; P < 0.01; VASP-PRI: WMD = − 9.61; 95% CI: − 14.63 to − 4.60; P = 0.002). No significant difference in HTPR based on PRU was identified between the ticagrelor and prasugrel groups (P = 0.71), whereas a lower HTPR based on VASP-PRI was found in the ticagrelor-treated patients than in the prasugrel-treated patients (RR = 0.30; 95% CI: 0.12–0.75; P = 0.010). In addition, the results showed a lower LTPR was observed in the prasugrel group than in the ticagrelor group (RR = 1.40; 95% CI: 1.08–1.81; P = 0.01). Conclusions Prasugrel might enable higher platelet reactivity than ticagrelor. Ticagrelor could lead to a decrease in HTPR and increase in LTPR. However, this result was only obtained in pooled observational studies. Several uncertainties such as the nondeterminancy of the effectiveness of ticagrelor estimated using VASP-PRI or the definition of HTPR (a high or modifiable risk factor) might have affected our results.

scholarly journals Anxiety and clinical outcomes of patients with acute coronary syndrome: a meta-analysis

BMJ Open ◽  
2020 ◽  
Vol 10 (7) ◽  
pp. e034135 ◽  
Author(s):  
Jie Li ◽  
Feng Ji ◽  
Junxian Song ◽  
Xiangyang Gao ◽  
Deguo Jiang ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Clinical Outcomes ◽  
Mortality Risk ◽  
Meta Analysis ◽  
Secondary Outcome ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Follow Up Studies ◽  
Poor Outcomes

ObjectivesAnxiety has been suggested to be associated with poor outcomes in patients with acute coronary syndrome (ACS). However, results of previous follow-up studies were inconsistent. The aim of this meta-analysis was to evaluate the association between anxiety and clinical outcomes in patients with ACS, and to investigate the potential role of depression underlying the above association.DesignA meta-analysis of prospective follow-up studies.SettingHospitals.ParticipantsPatients with ACS.InterventionsWe included related prospective follow-up studies up through 20 July 2019 that were identified by searching PubMed and Embase databases. A random-effect model was used for the meta-analysis. Anxiety was evaluated by validated instruments at baseline.Primary and secondary outcome measuresWe determined the association between anxiety and risks of mortality and adverse cardiovascular events (MACEs) in patients with ACS.ResultsOur analysis included 17 studies involving 39 038 patients wqith ACS. Anxiety was independently associated with increased mortality risk (adjusted risk ratio (RR) 1.21, 95% CI 1.07 to 1.37, p=0.002) and MACEs (adjusted RR 1.47, 95% CI 1.24 to 1.74, p<0.001) in patients with ACS. Subgroup analyses showed that depression may at least partly confound the association between anxiety and poor outcomes in patients with ACS. Adjustment of depression significantly attenuated the association between anxiety and MACEs (adjusted RR 1.25, 95% CI 1.04 to 1.52, p=0.02). Moreover, anxiety was not significantly associated with mortality risk after adjusting for depression (adjusted RR 0.88, 95% CI 0.66 to 1.17, p=0.37).ConclusionsAnxiety is associated with increased risk of mortality and MACEs in patients with ACS. However, at least part of the association may be confounded by concurrent depressive symptoms in these patients.

scholarly journals CHA2DS2-VASc risk factors as predictors of stroke after acute coronary syndrome: A systematic review and meta-analysis

2016 ◽  
Vol 7 (3) ◽  
pp. 264-274 ◽  
Author(s):  
Federico Guerra ◽  
Lorena Scappini ◽  
Alessandro Maolo ◽  
Gianluca Campo ◽  
Rita Pavasini ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Acute Coronary Syndrome ◽  
Confidence Interval ◽  
Transient Ischemic Attack ◽  
Odds Ratio ◽  
Observational Studies ◽  
Meta Analysis ◽  
Odds Ratios ◽  
Coronary Syndrome ◽  
Ischemic Attack

Background: Stroke is a rare but serious complication of acute coronary syndrome. At present, no specific score exists to identify patients at higher risk. The aim of the present study is to test whether each clinical variable included in the CHA2DS2-VASc score retains its predictive value in patients with recent acute coronary syndrome, irrespective of atrial fibrillation. Methods: The meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. All clinical trials and observational studies presenting data on the association between stroke/transient ischemic attack incidence and at least one CHA2DS2-VASc item in patients with a recent acute coronary syndrome were considered in the analysis. Atrial fibrillation diagnosis was also considered. Results: The whole cohort included 558,193 patients of which 7108 (1.3%) had an acute stroke and/or transient ischemic attack during follow-up (median nine months; 1st–3rd quartile 1–12 months). Age and previous stroke had the highest odds ratios (odds ratio 2.60; 95% confidence interval 2.21–3.06 and odds ratio 2.74; 95% confidence interval 2.19–3.42 respectively), in accordance with the two-point value given in the CHA2DS2-VASc score. All other factors were positively associated with stroke, although with lower odds ratios. Atrial fibrillation, while present in only 11.2% of the population, confirmed its association with an increased risk of stroke and/or transient ischemic attack (odds ratio 2.04; 95% confidence interval 1.71–2.44). Conclusions: All risk factors included in the CHA2DS2-VASc score are associated with stroke/ transient ischemic attack in patients with recent acute coronary syndrome, and retain similar odds ratios to what already seen in atrial fibrillation. The utility of CHA2DS2-VASc score for risk stratification of stroke in patients with acute coronary syndrome remains to be determined.

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