Network meta-analysis of prasugrel, ticagrelor, high- and standard-dose
clopidogrel in patients scheduled for percutaneous coronary interventions.
Author(s): Steiner S, Moertl D, Chen L, Coyle D, Wells GA.
Affiliation(s): Department of Internal Medicine II, Division of Angiology, Medical University
Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
sabine.m.steiner@meduniwien.ac.at
Publication date & source: 2012, Thromb Haemost. , 108(2):318-27
Since novel antiplatelet treatments (prasugrel, ticagrelor, high-dose
clopidogrel) have been predominantly tested against standard-dose clopidogrel,
data on direct comparisons between these therapies are scarce. We therefore
indirectly compared their efficacy and safety in patients undergoing percutaneous
coronary intervention. Electronic databases were searched systematically to
identify head-to-head randomised controlled trials (RCTs). Network meta-analysis
was performed using generalised linear mixed models with adjustment for length of
follow-up. Findings were corroborated by mixed treatment comparison through
Bayesian methods. Fourteen RCTs were identified and included in the analysis
(high- vs. standard-dose clopidogrel: 9 trials, prasugrel vs. high-dose
clopidogrel: 2 trials, prasugrel vs. standard-dose clopidogrel: 2 trials,
ticagrelor vs. standard-dose clopidogrel: 1 trial). No significant differences
were found for efficacy outcomes except for stent thrombosis favouring prasugrel
(vs. ticagrelor: odds ratio [OR] 0.63, 95% confidence interval [CI]: 0.42, 0.94;
vs. high-dose clopidogrel: OR 0.70, 95%CI: 0.48, 1.01). Prasugrel exhibited a
similar bleeding risk as high-dose clopidogrel, but more major (OR 1.43, 95%CI
1.07, 1.90) and major or minor bleeding (OR 1.36, 95%CI 1.09, 1.69) compared to
ticagrelor. Ticagrelor was also associated with less major or minor bleeding
compared to high-dose clopidogrel (OR 0.81, 95%CI 0.69, 0.96). No differences
were seen for non CABG-related major bleeding between the three strategies.
Results were corroborated in a subgroup analysis comprising only patients with
acute coronary syndromes. In the absence of head-to-head clinical trials, network
meta-analysis suggests potentially relevant differences in efficacy and bleeding
risk among novel antiplatelet treatments and may thereby advance understanding of
their differential therapeutic properties.
|