Monotherapy with a P2Y12 inhibitor or aspirin for secondary prevention in patients with established atherosclerosis: a systematic review and meta-analysis

Review of 9 RCTs (n=42,108) found that P2Y12 inhibitor monotherapy had a lower risk of MI (OR 0.81 95%CI 0.66-0.99) and a comparable risk of stroke and all cause mortality (0.93, 0.82-1.06 and 0.98, 0.89-1.08). Findings were consistent regardless of P2Y12 inhibitor.

SPS commentary:

There was a similar risk of major bleeding (OR 0.90, 95%CI 0.74-1.10).  Authors highlight that NNT to prevent 1 additional MI was 244, which is of debatable clinical relevance given no difference in other endpoints.


A related commentary states that, despite these results, in the broader context, it could be noted that aspirin monotherapy remains the standard-of-care for secondary prevention of cardiovascular disease. Efforts to either replace aspirin with other antiplatelet agents or improve on its efficacy and safety profile by adding a P2Y12 inhibitor or a low-dose anticoagulant have not produced results convincing enough to induce a major change in guideline recommendations. Guidelines from the European Society of Cardiology updated in 2019 continue to recommend aspirin as the drug of choice for secondary prevention in patients with chronic coronary syndrome, particularly those with prior myocardial infarction and revascularisation. In these guidelines, clopidogrel is recommended as an alternative and makes sense in patients with aspirin intolerance or heightened risk of gastrointestinal bleeding.


The Lancet

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