Am Heart J. 2021 Mar 15:S0002-8703(21)00075-2. doi: 10.1016/j.ahj.2021.03.009. Online ahead of print.
BACKGROUND: Potent P2Y12 inhibitors reduce cardiovascular events but increase bleeding in patients presenting with acute coronary syndrome (ACS). Elderly patients are at increased risk of bleeding and whether the benefit-risk ratio of potent P2Y12 inhibitors remains favorable is not known.
OBJECTIVES: To investigate the efficacy and safety of potent P2Y12 inhibitors versus clopidogrel in elderly patients with ACS.
METHODS: PUBMED and EMBASE were searched through July 2020 for randomized control trials (RCTs) or subgroup analyses of RCTs investigating potent P2Y12 inhibitors (prasugrel or ticagrelor) or clopidogrel in elderly (age ≥ 65 years) patients with ACS. The primary outcome was major adverse cardiovascular events (MACE).
RESULTS: Our search identified 9 RCTs with a total of 10,792 elderly patients. When compared with clopidogrel, potent P2Y12 inhibitors had similar risk of MACE (hazard ratio (HR): 0.94; 95%; confidence interval (CI) [0.85-1.06], P=0.31, I2=9%), all-cause mortality (HR: 0.89; 95% CI [0.74-1.07], P=0.22, I2=29%), reduced the risk of cardiovascular death (HR: 0.82; 95% CI [0.68-0.98], P=0.03, I2=16%) but increased the risk of major bleeding (HR: 1.27; 95% CI [1.04-1.56], P=0.02, I2=0%). In a subgroup analysis, ticagrelor reduced all-cause mortality (HR: 0.73; 95% CI [0.55-0.98]) and cardiovascular death (HR: 0.70; 95% CI [0.54-0.90]) compared with clopidogrel.
CONCLUSIONS: Among elderly patients with ACS, potent P2Y12 inhibitors reduce cardiovascular death but increase bleeding with no difference in MACE or all-cause death when compared with clopidogrel. Further RCTs are needed to refine P2Y12 inhibitor selection for elderly patients with ACS.