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11 Optimal P2Y12 Blockade in Oral Dual Antiplatelet Therapy for Women with Coronary Heart Disease – A Systematic Review and Meta-Analysis
  1. Oliver Brown1,
  2. Jennifer Rossington2,
  3. Angela Hoye2
  1. 1Hull York Medical School
  2. 2University of Hull

Abstract

Introduction Current European and American guidelines indicate the use of P2Y12 inhibitors in the management of patients with acute coronary syndromes and post coronary intervention. In recent times, newer P2Y12 inhibitors such as ticagrelor and prasugrel have been shown to be clinically superior to clopidogrel at reducing mortality. However contrary to this statement some of large randomised controlled trials (RCT) investigating these newer agents have not shown a significant benefit in women. The aim of our meta-analysis is to ascertain which is the superior P2Y12inhibitor in the management of coronary heart disease (CHD) in women.

Methods Using a defined-search strategy, electronic databases (MEDLINE and Embase) were searched for papers published between 1946–2014, and abstracts from major cardiology conferences to 8th June 2014. For inclusion they had to be RCT in design with clinical outcomes for P2Y12 inhibitors in adult female patients with coronary heart disease. Nine eligible studies comparing P2Y12 inhibitors were identified and appraised using set criteria by two independent authors who then extracted the relevant data. Six of these studies compared clopidogrel to a control group; two compared prasugrel to clopidogrel and one compared ticagrelor to clopidogrel. Combined, these studies recruited a total of 31579 female patients. Risk ratios (RR) and their 95% confidence intervals (CI) were calculated for a composite endpoint of cardiovascular death, myocardial infarction (MI) or stroke. We then used indirect comparison analyses to compare prasugrel and ticagrelor against the control arm in their original trials.

Results When compared to aspirin alone, clopidogrel was shown to be efficacious at reducing the risk of developing the composite endpoint with a RR of 0.92 (CI: 0.85–0.99, p = 0.03) (Figure 1). Additionally when compared to clopidogrel therapy, ticagrelor was shown to reduce the risk of developing the composite endpoint with a RR of 0.84 (95% CI: 0.72–0.97 p = 0.02) whilst prasugrel was shown to have a non-statistically significant benefit with a RR of 0.93 (95% CI: 0.82–1.06, p = 0.27). When indirectly comparing ticagrelor to prasugrel, a weak trend suggesting ticagrelor to be superior to prasugrel was observed with a RR of 0.90 (95% CI: 0.74–1.10), but this was not statistically significant (Figure 2).

Abstract 11 Figure 1

Forest plot showing the risk ratio of developing the composite endpoint of cardiovascular death, MI and stroke from taking clopidogrel vs control in women

Abstract 11 Figure 2

Risk ratio for developing the composite endpoint of cardiovascular death, MI or stroke when comparing clopidogrel, prasugrel, ticagrelor and controls in mixed treatment comparisons

Conclusions P2Y12 inhibitors are of clinical benefit in women with CHD. Ticagrelor is superior to clopidogrel therapy, and has a possible weak trend to superiority over prasugrel in the management of female patients with CHD.

  • P2Y12 inhibitors
  • coronary heart disease
  • meta-analysis

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