Physicians' Academy for Cardiovascular Education

A guided selection of P2Y12i therapy in ACS patients has most favorable profile

Comparative effects of guided vs. potent P2Y12 inhibitor therapy in acute coronary syndrome: a network meta-analysis of 61,898 patients from randomized trials

Literature - Galli M, Benenati S, Franchi F et al., - Eur Heart J 2021;

Introduction and methods


Platelet function and genetic testing can be used as tools to guide P2Y12 inhibitor therapy to administer the more potent P2Y12 inhibitors ticagrelor and prasugrel to clopidogrel poor responders [1,2]. No consistent results on the effect of a guided selection of antiplatelet therapy were observed in RCTs, but a meta-analysis demonstrated that a guided selection of antiplatelet therapy was associated with improved outcomes compared to standard selection of antiplatelet therapy in patients undergoing PCI [3]. Data on the acute setting are lacking.

In this network meta-analysis the safety and efficacy of oral P2Y12 inhibitor strategies, including a guided selection approach by platelet function or genetic testing, was examined for the treatment used in the setting of ACS.

Study design

RCTs comparing oral P2Y12 inhibitors for the treatment of patients with ACS (clopidogrel, prasugrel, ticagrelor) were included. RCTs including a guided approach vs. standard selection of P2Y12 inhibitors in patients with ACS were also included. A systematic search was done in large databases using search terms.

15 RCTs with a total of 61,898 patients and mean follow-up of 11.9 months were included in the analysis.

Clopidogrel represented the reference treatment.

Primary outcomes

Primary efficacy outcome was MACE, as defined in each individual included trial. Primary safety endpoint was all bleeding.

Main results

Primary outcome

Secondary outcomes

Ranking of treatment strategies

A guided selection of P2Y12i therapy in ACS patients has most favorable profile


This comprehensive network meta-analysis including 61,898 patients from 15 RCTs, in which different P2Y12 inhibiting strategies were compared in ACS patients, showed that a guided selection of P2Y12 inhibiting therapy had the most favorable safety and efficacy profile; significant protection against ischemic recurrences without enhancing the risk of bleeding.

The authors write: “These findings support a broader adoption of tools, including platelet function and genetic testing, to enable a more personalized selection of antiplatelet therapy among patients with ACS.”


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