Antithrombotic therapy in the early phase of NSTE-ACS: a systematic review and meta-analysis.

AIMS: Despite the increasing use of early invasive strategies in non-ST-elevation acute coronary syndromes (NSTE-ACS), optimal initial antithrombotic therapy (ATT) based on the safety/efficacy profile of all guideline-recommended combinations remains crucial for the early management of both medically and invasively treated NSTE-ACS patients. METHODS AND
RESULTS: Randomised controlled trials (RCTs) on ATT in NSTE-ACS/unstable angina reporting early (within 14 days) major adverse cardiovascular events (MACE) and major bleeding were selected. Overall, 3799 studies were screened, 117 clinical trials were assessed as potentially eligible, 20 trials were included in the study. According to treatment and type of intervention, 9 different meta-analyses were performed including a total of 88,748 patients. A significant reduction of trial-defined MACE was found for aspirin vs placebo (OR, 0.57; 95% CI, 0.34-0.96), heparin vs placebo (OR, 0.38; 95% CI, 0.15-0.97), aspirin+heparin vs placebo (OR, 0.32; 95% CI, 0.18-0.59), aspirin+heparin vs aspirin (OR, 0.57; 95% CI, 0.42-0.79), aspirin+LMWH vs aspirin+UFH (OR, 0.81; 95% CI, 0.69-0.95) and aspirin+ticagrelor/prasugrel+heparins vs aspirin+clopidogrel+heparins (OR, 0.76; 95% CI, 0.62-0.94). A significant decrease in major bleeding was found only for fondaparinux vs LMWH on the background of aspirin+clopidogrel (OR, 0.52; 95% CI, 0.44-0.62) despite a clear trend in increased bleeding for heparin compared to aspirin, aspirin+heparin compared to placebo, aspirin+heparin compared to aspirin, aspirin+P2Y12inhibitors+UFH/LMWH compared to aspirin+UFH/LMWH and aspirin+ticagrelor/prasugrel+heparins vs aspirin+clopidogrel+heparins.
CONCLUSION: To our knowledge, these findings are the first to report the safety and efficacy of all the various combinations of currently recommended ATT for the early management of NSTE-ACS, providing a comprehensive evidence-base to guide decisions depending on the patients' bleeding risk and treatment strategy. © Published on behalf of the European Society of Cardiology. All rights reserved.