Genotype-guided antiplatelet therapy after percutaneous coronary intervention: a systematic review and meta-analysis of randomised controlled trials
A Iaconelli, M Busti, F Di Pasquale, S Proietti, A Roscioli, S Morini, A Buffon, C Trani, F Burzotta, S Boccia, G LiuzzoAbstract
Background
the clinical benefit of genotype-guided antiplatelet therapy compared with standard treatment in patients undergoing percutaneous coronary intervention (PCI) remains uncertain. We conducted a systematic review and meta-analysis to assess the impact of a genetic testing–guided strategy on ischaemic and safety outcomes after PCI.
Methods
electronic databases were systematically searched to identify randomised controlled trials comparing genotype-guided versus standard antiplatelet therapy in patients undergoing PCI. After screening the retrieved records, eligible trials were included in a meta-analysis. Pooled effect estimates were calculated as incidence rate ratios (IRRs) with 95% confidence intervals (CIs) using random-effects models. Analyses were performed in the overall population and according to clinical presentation (acute versus chronic coronary syndromes).
Results
our analysis included 8 randomised controlled trials with data for 10,850 patients. Compared with standard therapy, genotype-guided antiplatelet selection was associated with a significant reduction in major adverse cardiovascular events (MACE) (IRR 0.63, 95% CI 0.43–0.94) and stent thrombosis (IRR 0.64, 95% CI 0.43–0.95). Stroke showed a borderline reduction in the overall population (IRR 0.65, 95% CI 0.41–1.01), reaching statistical significance in the acute coronary syndrome cohort (IRR 0.56, 95% CI 0.33–0.97). No significant differences were observed for all-cause mortality (IRR 0.65, 95% CI 0.31–1.38) or cardiovascular mortality (IRR 0.70, 95% CI 0.40–1.21). Similarly, major bleeding (IRR 0.86, 95% CI 0.63–1.16) and minor bleeding (IRR 0.78, 95% CI 0.56–1.09) did not differ significantly between strategies. Subgroup analyses according to acute or chronic clinical presentation did not reveal significant interactions; however, these analyses were limited by the small number of patients within each subgroup and wide confidence intervals.
Conclusions
in patients undergoing PCI, a genotype-guided antiplatelet strategy is associated with improved ischaemic outcomes, particularly through reductions in MACE and stent thrombosis, without an excess of bleeding. However, no significant reduction in all-cause or cardiovascular mortality was observed. These findings support a selective role for genetic testing in tailoring antiplatelet therapy, while highlighting the need for adequately powered studies to clarify effects on hard mortality endpoints.Major Adverse Cardiovascular Events (MACE)ACM and CVM outcomes