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Minerva Cardiology and Angiology 2021 August;69(4):398-407

DOI: 10.23736/S2724-5683.20.05353-0


language: English

Antiplatelet strategies in acute coronary syndromes: design and methodology of an international collaborative network meta-analysis of randomized controlled trials

Mahesh V. MADHAVAN 1, 2, Behnood BIKDELI 1, 2, 3, 4, Björn REDFORS 1, 2, 5, Giuseppe BIONDI-ZOCCAI 6, 7, Nicholas J. VARUNOK 1, John R. BURTON 1, Aaron CROWLEY 2, Dominic P. FRANCESE 2, Aakriti GUPTA 1, 2, Caroline DER NIGOGHOSSIAN 1, Saurav CHATTERJEE 8, Tullio PALMERINI 9, Umberto BENEDETTO 10, Seng C. YOU 11, Erik M. OHMAN 12, Adnan KASTRATI 13, 14, Philippe G. STEG 15, Charles M. GIBSON 16, Dominick J. ANGIOLILLO 17, Harlan M. KRUMHOLZ 18, Gregg W. STONE 2, 19

1 Columbia University Irving Medical Center and the NewYork-Presbyterian Hospital, New York, NY, USA; 2 Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; 3 Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; 4 Yale/YNHH Center for outcomes Research and Evaluation (CORE), New Haven, CT, USA; 5 Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; 6 Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy; 7 Mediterranea Cardiocentro, Naples, Italy; 8 St. Francis Hospital, Hartford, CT, USA; 9 Unit of Cardiology, S. Orsola Polyclinic, Bologna, Italy; 10 University of Bristol, Bristol, UK; 11 Ajou University, Suwon, South Korea; 12 Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; 13 Deutsches Herzzentrum München (DHM), Technical University of Munich, Munich, Germany; l4 DZHK - German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany; 15 INSERM U-1148, French Alliance for Cardiovascular Trials (FACT), Bichat Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Paris, France; 16 Beth Israel Deaconess Medical Center, Boston, MA, USA; 17 Division of Cardiology, College of Medicine, University of Florida, Jacksonville, FL, USA; 18 Yale School of Medicine, New Haven, CT, USA; 19 The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA

INTRODUCTION: The optimal choice of oral P2Y12 receptor inhibitors has the potential to significantly influence outcomes. We seek to compare the safety and efficacy of the three most commonly used oral P2Y12 receptor inhibitors (clopidogrel, prasugrel, and ticagrelor) in acute coronary syndromes (ACS) via a comprehensive systematic review and network meta-analysis.
EVIDENCE ACQUISITION: In line with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines, we performed a comprehensive search for RCTs which compared cardiovascular and hemorrhagic outcomes after use of at least two of the distinct oral P2Y12 receptor inhibitors (i.e. clopidogrel, prasugrel, and ticagrelor). A search strategy has been designed to systematically search multiple databases, including MEDLINE with PubMed interface, The Cochrane Central Register of Controlled Trials, and Embase. In addition, key inclusion criteria will be trial size of at least 100 patients and at least 1 month of follow-up time. Several prespecified subgroups will be explored, including Asian patients, patients presenting with ST-elevation myocardial infarction, patients of advanced age, and others.
EVIDENCE SYNTHESIS: Exploratory frequentist pairwise meta-analyses will be based primarily on a random-effects method, relying on relative risks (RR) for short-term outcomes and incidence rate ratios (IRR) for long-term outcomes. Inferential frequentist network meta-analysis will be based primarily on a random-effects method, relying on RR and IRR as specified above. Results will be reported as point summary of effect, 95% CI, and P values for effect, and graphically represented using forest plots.
CONCLUSIONS: An international collaborative network meta-analysis has begun to comprehensively analyze the safety and efficacy of prasugrel, ticagrelor and clopidogrel, each on a background of aspirin, for management of patients with ACS. It is our hope that the rigor and breadth of the undertaking described herein will provide novel insights that will inform optimal patient care for patients with ACS treated conservatively, or undergoing revascularization.

KEY WORDS: Platelet aggregation inhibitors; Purinergic P2Y receptor antagonists; Acute coronary syndrome; Network meta-analysis

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