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Newer P2Y12 Inhibitors vs Clopidogrel in Acute Myocardial Infarction With Cardiac Arrest or Cardiogenic Shock: A Systematic Review and Meta-analysis



      To evaluate the outcomes, safety, and efficacy of dual antiplatelet therapy (DAPT) with newer P2Y12 inhibitors compared with clopidogrel in patients with acute myocardial infarction (AMI) complicated by cardiac arrest (CA) or cardiogenic shock (CS).

      Patients and Methods

      MEDLINE, EMBASE, and the Cochrane Library were queried systematically from inception to January 2021 for comparative studies of adults (≥18 years) with AMI-CA/CS receiving DAPT with newer P2Y12 inhibitors as opposed to clopidogrel. We compared outcomes (30-day or in-hospital and 1-year all-cause mortality, major bleeding, and definite stent thrombosis) of newer P2Y12 inhibitors and clopidogrel in patients with AMI-CA/CS.


      Eight studies (1 randomized trial and 7 cohort studies) comprising 1100 patients (695 [63.2%] receiving clopidogrel and 405 [36.8%] receiving ticagrelor or prasugrel) were included. The population was mostly male (68.5%-86.7%). Risk of bias was low for these studies, with between-study heterogeneity and subgroup differences not statistically significant. Compared with the clopidogrel cohort, the newer P2Y12 cohort had lower rates of early mortality (odds ratio [OR], 0.60; 95% CI, 0.45 to 0.81; P=.001) (7 studies) and 1-year mortality (OR, 0.51; 95% CI, 0.36 to 0.71; P<.001) (3 studies). We did not find a significant difference in major bleeding (OR, 1.21; 95% CI, 0.71 to 2.06; P=.48) (6 studies) or definite stent thrombosis (OR, 2.01; 95% CI, 0.63 to 6.45; P=.24) (7 studies).


      In patients with AMI-CA/CS receiving DAPT, compared with clopidogrel, newer P2Y12 inhibitors were associated with lower rates of early and 1-year mortality. Data on major bleeding and stent thrombosis were inconclusive.

      Abbreviations and Acronyms:

      ACS (acute coronary syndrome), AMI (acute myocardial infarction), ARC (Academic Research Consortium), BARC (Bleeding Academic Research Consortium), CA (cardiac arrest), CABG (coronary artery bypass grafting), CPR (cardiopulmonary resuscitation), CS (cardiogenic shock), DAPT (dual antiplatelet therapy), Gp (glycoprotein), HBR (high bleeding risk), ICU (intensive care unit), NR (not reported), OHCA (out-of-hospital cardiac arrest), OR (odds ratio), PCI (percutaneous coronary intervention), PFA (platelet function assay), ROSC (return of spontaneous circulation), STEMI (ST-segment elevation myocardial infarction), TIMI (Thrombolysis in Myocardial Infarction), TTM (targeted temperature management), VF (ventricular fibrillation), VT (ventricular tachycardia)
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