P2Y12i monotherapy vs. aspirin monotherapy in patients with CAD

ESC 2022 A meta-analysis shows that P2Y12 inhibitor monotherapy lowered the primary endpoint of CV death, MI or stroke compared to aspirin monotherapy in patients with CAD.

Presented at the ESC congress 2022 by: Marco Valgimigli, MD, PhD – Lugano, Switzerland

Introduction and methods

The investigators searched for studies comparing aspirin with any P2Y12 inhibitor. Seven trials were identified including 35,752 individual participants from 492 sites across Asia, Europe and North-America. After excluding patients without established coronary artery disease and censoring patients with events during an early DAPT phase, the study population consisted of 24,325 patients. A total of 12,178 patients were assigned to P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 patients to aspirin monotherapy. Median treatment duration was 557 days.

The primary endpoint was a composite of CV death, MI or stroke.

Main results

• The primary endpoint occurred in 5.5% of patients on P2Y12 inhibitor monotherapy vs. 6.3% in the aspirin monotherapy group (HR 0.88, 95%CI:0.79-0.97, P=0.014).
• There was no difference in the secondary outcomes of death and CV death.
• MI event rate was lower in the P2Y12 inhibitor monotherapy group compared with the aspirin monotherapy group (HR 0.77, 95%CI:0.66-0.90, P<0.001).
• There was a trend for lower incidence of stroke with P2Y12 inhibitor monotherapy, but this did not reach statistical significance. Hemorrhagic stroke was lowered by P2Y12 inhibitor monotherapy (HR 0.32, 95%CI:0.14-0.75, P=0.009).
• GI bleeding was reduced in the P2Y12 inhibitor monotherapy group compared with the aspirin monotherapy group (HR 0.75, 95%CI:0.53-0.97, P=0.027).

Conclusion

This meta-analysis showed a lower risk of the composite outcome of CV death, MI or stroke with P2Y12 inhibitor monotherapy compared with aspirin monotherapy in patients with coronary artery disease. This was driven by a lower risk of MI. A reduced risk of net adverse clinical events was seen with P2Y12 inhibitor monotherapy compared with aspirin monotherapy.

Major bleeding incidence was not different between the two groups, but gastrointestinal bleeding and hemorrhagic stroke were lower with P2Y12 inhibitor monotherapy.

Marco Valgimigigli said that “long-term P2Y12 inhibitor monotherapy may be warranted instead of long-term aspirin monotherapy for secondary prevention in patients with coronary artery disease.”

• Our reporting is based on the information provided at the ESC Congress -