Optimal P2Y12inhibition in older adults with acute coronary syndromes: A network meta-analysis of randomized controlled trials

Claudio Montalto, Nuccia Morici, Andrea Raffaele Munafò, Antonio Mangieri, Alessandro Mandurino-Mirizzi, Fabrizio D'Ascenzo, Jacopo Oreglia, Azeem Latib, Italo Porto, Antonio Colombo, Stefano Savonitto, Stefano De Servi, Gabriele Crimi

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


Aims: Dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor on top of aspirin is the cornerstone of therapy after acute coronary syndromes (ACS). Nonetheless, the safest and most efficacious P2Y12 for older patients who are both at high ischaemic and bleeding risk remains uncertain. We aimed to examine the effect of available P2Y12 inhibitors on ischaemic and bleeding endpoints in older adults with ACS. Methods and results: Randomized clinical trials that reported separately the results of adults older >70 years for at least the primary endpoint [composite of death, myocardial infarction (MI), and stroke]. Seven studies (14 485 patients-years) were included. Network meta-analysis showed that prasugrel was associated with similar occurrence of the primary endpoint and of a secondary ischaemic endpoint (composite of MI and stroke) and was most likely the best treatment [Surface Under the Cumulative Ranking curve Analysis (SUCRA) 54.5 and 59.8, respectively]. With regards to major bleedings, clopidogrel showed the highest likelihood of event reduction (SUCRA 70.1%), while ticagrelor of stent thrombosis (SUCRA 55.6%). Our meta-regression with a fixed proportion of patients managed invasively of 100% confirmed these trends with increasing SUCRA. Conclusion: Among older subjects with ACS, DAPT should be balanced upon ischaemic and bleeding risks as prasugrel is associated with the highest probability of reduction of ischaemic events and clopidogrel of bleedings. Ticagrelor had highest SUCRA for stent thrombosis reduction but seems suboptimal in older adults.

Original languageEnglish (US)
Pages (from-to)20-27
Number of pages8
JournalEuropean Heart Journal - Cardiovascular Pharmacotherapy
Issue number1
StatePublished - Jan 1 2022


  • Acute coronary syndromes
  • Clopidogrel
  • DAPT
  • Elderlies
  • P2Y12
  • Prasugrel
  • Ticagrelor

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Pharmacology (medical)


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