PANTHER - P2Y12 inhibitor versus aspirin monotherapy in patients with coronary artery disease
Reported from ESC Congress 2022
Elad Asher provides his take on the PANTHER trial which was presented at the ESC Congress 2022 in Barcelona
Rationale: For a very long time aspirin has been considered the antiplatelet of choice for long-term secondary prevention in patients with coronary artery disease (CAD). Nevertheless, the relative efficacy and safety of monotherapy with a P2Y12 inhibitor versus aspirin were not completely understood for patients with established CAD.
To better understand this issue, the PANTHER investigators performed a meta-analysis which included patient data from several randomized trials that included a comparison of P2Y12 inhibitor or aspirin monotherapy in patients with established CAD.
Design: The analysis, from seven randomized controlled trials, included 24,325 patients. Of them 12,178 were assigned to P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 were assigned to aspirin monotherapy. The median treatment duration was 557 days. The average age of participants was 64.3 years and 21.7% were women.
Endpoints: The primary endpoint was a composite of cardiovascular (CV) death, myocardial infarction (MI) or stroke and occurred in 5.5% of patients on P2Y12 inhibitor monotherapy vs. 6.3% in the aspirin monotherapy group (HR 0.88, 95% CI:0.79-0.97, P=0.014). (NNT to prevent one adverse outcome was 123 patients).
Secondary outcomes:
- Death and CV death -NS
- MI event rate was lower in the P2Y12 inhibitor monotherapy group compared with the aspirin monotherapy group (HR 0.77, 95% CI:0.66-0.90, P<0.001).
- A trend toward lower incidence of stroke with P2Y12 inhibitor monotherapy (although it did not reach statistical significance).
- Haemorrhagic stroke was lowered in the P2Y12 inhibitor monotherapy (HR 0.32, 95% CI:0.14-0.75, P=0.009).
- GI bleeding was lower in the P2Y12 inhibitor monotherapy (HR 0.75, 95% CI:0.53-0.97, P=0.027).
The authors concluded that the meta-analysis showed a lower risk of the composite outcome of CV death, MI or stroke with P2Y12 inhibitor monotherapy compared with aspirin monotherapy in patients with coronary artery disease.
This was driven mainly by a lower risk of MI. A reduced risk of net adverse clinical events was seen with P2Y12 inhibitor monotherapy compared with aspirin monotherapy.
Major bleeding incidence was not different between the two groups, but gastrointestinal bleeding and hemorrhagic stroke were lower with P2Y12 inhibitor monotherapy.
Based on the available data, long-term P2Y12 inhibitor monotherapy may be warranted instead of long-term aspirin monotherapy for secondary prevention in patients with CAD.
How will PANTHER impact your practice?
The PANTHER study: P2Y12 Inh monotherapy (compared with ASA), associated with lower risks of CV death, MI/stroke, similar rates of major bleeding. What would you give to you patients? @PCRonline@Sbrugaletta@Ortega_Paz@aayshacader@Anazmicalik@guilbom@hect2701@NicolaRyanI1
— Elad Asher (@AsherElad) August 29, 2022
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