A meta-analysis of efficacy and safety of genotype-guided versus standard of care treatment strategies in selecting antiplatelet therapy in patients with acute coronary syndrome

Background Previous studies have shown similar rates of major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS) patients, treated with P2Y(12) inhibitors based on genotype guidance compared to standard treatment. However, given lower than expected event rates, these studies were underpowered to assess hard outcomes. We sought to systematically analyze this evidence using pooled data from multiple studies. Methods Electronic databases were searched for studies of ACS patients that underwent genotype-guided treatment (GGT) with P2Y(12) inhibitors versus standard of care treatment (SCT). Studies with a minimum follow-up of 12 months were included. Rate of MACE (defined as a composite of cardiovascular [CV] mortality, nonfatal myocardial infarction [MI], and nonfatal stroke) was the primary outcome. Secondary outcomes were individual components of MI, CV mortality, ischemic stroke, stent thrombosis, and major bleeding. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated and combined using random effects model meta-analysis. Results A total of 4,095 patients (2007 in the GGT and 2088 in the SCT group were analyzed from three studies). Significantly lower odds of MACE (6.0 vs. 9.2%; OR: 0.63, 95% CI: 0.50-0.80, p < .001, I-2 = 0%) and MI (3.3 vs. 5.45%; OR: 0.63; CI 0.41-0.96; p = .03; I-2 = 46%) were noted in the GGT group compared to SCT. No significant difference was noted with respect to CV and other secondary outcomes. Conclusion In patients with ACS, genotype-guided initiation of P2Y(12) inhibitors was associated with lower odds of MACE and similar bleeding risk in comparison to SCT.