28 More Versus Less-intensive Platelet Inhibition in Acute Coronary Syndromes: A Meta-analysis of Randomised-Controlled Trials

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Notwithstanding potent dual antiplatelet therapy (DAT), a significant proportion of individuals with acute coronary syndromes (ACS) develop future cardiovascular disease (CVD) events. We therefore sought to assess the efficacy and safety of more intensive platelet inhibition for ACS by conducting a literature-based meta-analysis of randomised-controlled trials (RCTs).


Four studies (with up to 64,561 participants) were included. Study-specific hazard ratios (HRs) were combined using random-effects meta-analysis, and heterogeneity was quantified using I2 statistic.


Three trials (TRITON-TIMI 38, PLATO and CURRENT-OASIS 7) reported on participants intended to undergo percutaneous coronary intervention (PCI), whilst two studies (PLATO and TRILOGY ACS) also reported data on people not intended for PCI. In the former group of studies, intensive platelet inhibition significantly reduced the risk of composite primary end-point (HR 0.83, 95% confidence interval 0.78–0.89), primarily due to a reduction in the risk of myocardial infarction (0.78, 0.72–0.85), with no effect on stroke (Figure 1). There was a modest yet significant decrease in the risk of CVD death and total mortality, and an excess risk of major bleeds (1.27, 1.08–1.50). Qualitatively similar findings were observed when people not intended for PCI were included in the analyses.


Intensive platelet inhibition significantly reduces the risk of future CVD events and death in people with ACS, albeit at a significantly elevated risk of major bleeding. Further study is needed to identify subgroups of participants having optimum risk-to-benefit ratios for such treatment.

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