Efficacy and safety of intensified antiplatelet therapy on the basis of platelet reactivity testing in patients after percutaneous coronary intervention: systematic review and meta-analysis.
BACKGROUND
ADP-specific platelet function assays were shown to predict thrombotic events, and might be helpful to select candidates for more potent antiplatelet therapy. We aimed to determine the efficacy and safety of giving intensified antiplatelet therapy on the basis of platelet reactivity testing for patients undergoing percutaneous coronary intervention (PCI).


METHODS
Electronic databases were searched to find prospective, randomized trials that reported the clinical impact of using an intensified antiplatelet protocol (repeated loading or elevated maintenance doses of clopidogrel, prasugrel or glycoprotein IIb/IIIa inhibitor) on the basis of ADP-specific platelet reactivity testing (VerifyNow, Multiplate, VASP or light transmission aggregometry) compared to standard-dose clopidogrel. Evaluated efficacy measures included cardiovascular death, non-fatal myocardial infarction and definite/probable stent thrombosis (ST), while major bleeding events were recorded as safety endpoint.


RESULTS
Between 2008 and 2011, 10 clinical trials comprising 4213 randomized patients were identified. Compared to standard antiplatelet therapy, the intensified protocol was associated with a significant reduction in cardiovascular mortality, ST and myocardial infarction (p<0.01 for all). There was no difference in the rate of major bleeding events between intensified and standard groups (p=0.44). Although the observed effects regarding mortality, ST and bleeding were not heterogeneous, meta-regression analysis revealed that the net clinical benefit of the intensified treatment significantly depended on the risk of ST with standard-dose clopidogrel (p=0.023).


CONCLUSIONS
Intensifying antiplatelet therapy on the basis of platelet reactivity testing reduces cardiovascular mortality and ST after PCI; however, the net benefit of this approach depends on the risk of ST with standard-dose clopidogrel.
University of Pécs, Heart Institute, Pécs, Hungary. daniel_aradi@yahoo.com
Dániel
D
Aradi
András
A
Komócsi
Matthew J
MJ
Price
Thomas
T
Cuisset
Hasan
H
Ari
Dobri
D
Hazarbasanov
Dietmar
D
Trenk
Dirk
D
Sibbing
Marco
M
Valgimigli
Laurent
L
Bonello
D006801:Humans; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000639:trends*; D015539:Platelet Activation / Q000187:drug effects* / Q000502:physiology; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000009:adverse effects; D010979:Platelet Function Tests / Q000639:trends; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D013927:Thrombosis / Q000097:blood / Q000517:prevention & control; D016896:Treatment Outcome
D010975:Platelet Aggregation Inhibitors