acute coronary syndrome

systematic review meta-analysis network meta-analysis

Select myocardial revascularizationcholesterol lowering interventionanticoagulantantiplatelets drugantithromboticsdirect factor Xa inhibitorsdirect oral anticoagulant (DAO)heparin (UFH or LMWH)New P2Y12 Inhibitorsanti-anginal drugscalcium channel blockersfibrinolysisnitratesoxygen therapy ACS (excluding AMI)All ACS (including AMI)All type of patientuncoded clinical condition ***elderly patientspatients with scheduled percutaneous coronary interventionunstable angina       antianginal drugsbivalirudincalcium-channel blockerscooling-off strategydirect thrombin inhibitorearly invasive strategyezetimibefibrinolyticlong term LMWHnitratesoral anticoagulantoral direct thrombin inhibitororal factor Xa inhibitoroxygen therapyP2Y12 receptor antagonistPAR-1 inhibitorplatelet aggregation inhibitorsreversible ADP receptor antagonistselective PAR-1 thrombin receptor antagonistshort term LMWHshort term UFHstatinssurgerysynthetic oligosaccharidethienopyridine atorvastatinfluvastatinpravastatinsimvastatinezetimibediltiazemnifedipineanistreplaseapixabanargatrobanaspirinatopaxarbivalirudincangrelorclopidogrelcoumadindabigatrandalteparindipyridamolEfegatranelinogrelenoxaparinfondaparinuxhirudininogatrannadroparinnitroglycerinotamixabanprasugrelranolazinerivaroxabansulfinpyrazonet-paticagrelorticlopidinetrapidiltriflusalUFHvorapaxarwarfarinximelagatran vs controlvs placebovs placebo and controlvs placebo or controlvs antiplatelet drugsvs aspirinvs clopidogrelvs eptifibatide + heparinvs heparinvs heparin+aGP2b3avs LMWHvs statinvs UFH       early initiation

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Group by Group by... nothing pathology treatment patient comparator classe classe comparator mechanism clinical condition MA  in first nothing pathology treatment patient comparator classe classe comparator mechanism clinical condition  in second nothing pathology treatment patient comparator classe classe comparator mechanism clinical condition  in third	Description Synopsis Comparison Treatments Patients Characteristics Method Risk of bias References None Tools Indexation					Results Global trial result Main results All results All result tag NCT results	Major bleeding (169)All cause death (127)cardiovascular events (125)myocardial infarction (fatal and non fatal) (106)Non fatal MI (81)Vascular death (61)Revascularization (49)myocardial infarction or death (46)Non fatal stroke (44)stroke (fatal and non fatal) (42)all cause death, non-fatal MI, thrombo-embolic stroke (38)Non vascular death (37)Cardiovascular death (36)recurrent angina (32)major or clinically relevant non-major bleeding (31)intracranial hemorrhage (27)fatal bleeding (24)Extracranial hemorrhage (24)Bleeding (23)Minor bleeding (22)Fatal bleeding (15)any bleedings (15)non cardiovascular death (15)In-hospital death (14)Deaths or MI (13)cardiac event (fatal and non fatal ) (13)cardiac death (12)Fatal MI (12)In-hospital death (12)all cause death, MI, stroke (12)In hospital non fatal MI (11)In hospital death or MI (11)cardiovascular events at 1 month (10)cardiovascular events at 4 months (10)rehospitalization (10)myocardial infarction at 30 days (10)major or minor bleeding (10)death at 30 days (10)stent thrombosis (9)ischemic stroke (9)major bleeding TIMI (8)death, MI, unplanned revascularization (8)CCS class III-IV angina (7)death, myocardial infarction, or recurrent at 30 days (6)refractory ischemia (6)ischemic events + bleeding (4)Major or minor TIMI bleeding (4)Stent thrombosis (any, end of follow up) (4)Urgent target-vessel revascularization (4)death, myocardial infarction, or recurrent at 14 days (4)long term MI (3)long term cardiovascular death (3)long term all cause death, MI (3)Long term death (3)long term cardiovascular events (3)Repeat intervention (2)Drop in platelet count of 50% (2)no angina (at 6 weeks) (2)CABG (2)1 year composite ischemia (2)major bleeding not related to CABG (2)1 year MI (2)1 year unplanned revascularization for ischemia (2)1 year death from any cause (2)TIMI minor bleeding (2)in hospital death (patient with acute MI) (2)MACE (2)Death or stroke or myocardial infarction (1)Positive 6-wk ETT (1)Coronary event (1)Adverse events (1)Coronary death (1)PTCA (1)Death, MI, stroke, refractory ischemia (1)complication of AMI (1)dysrrhythmias (1)Recurrent ischemia (1) Options Numeric bar chart forest plot medians
Trial	Studied trt	Control trt	patients	tags	ROB	Trial result	Major bleeding	All cause death
anti-anginal drugs
ranolazine
MERLIN TIMI 36, 2007      NCT	ranolazine	placebo			Low risk of bias	suggesting
anticoagulant
apixaban
APPRAISE-1 (10mg od), 2009      NCT	apixaban	placebo			Low risk of bias	negative
APPRAISE-1 (2.5 mg bid), 2009      NCT	apixaban	placebo			Low risk of bias	negative
APPRAISE 2, 2011      NCT	apixaban	placebo			Low risk of bias	negative
coumadin
ASPECT-2 (coumadin+asp vs asp), 2002	coumadin	control (on top of aspirin)				suggesting
ASPECT-2 (coumadin vs aspirin), 2002	coumadin	aspirin				suggesting
dabigatran
REDEEM, 2009    NCT	dabigatran	placebo			Low risk of bias	negative
otamixaban
SEPIA-ACS1 TIMI 42, 2009    NCT	otamixaban	unfractionated heparin			Low risk of bias	suggesting
rivaroxaban
ATLAS ACS 2 - TIMI 51 (2.5mg), 2011      NCT	rivaroxaban 2.5mg	placebo			Low risk of bias	suggesting
ATLAS ACS-TIMI 46 (2.5mg), 2009      NCT	rivaroxaban 2.5mg	placebo			Low risk of bias	negative
ATLAS ACS 2 - TIMI 51 (5mg), 2011      NCT	rivaroxaban 5mg	placebo				suggesting
ATLAS ACS-TIMI 46 (5mg), 2009      NCT	rivaroxaban 5mg	placebo			Low risk of bias	negative
warfarin
ATACS (pilot study) (warfarin vs control), 1990	warfarin	control (on top of aspirin)				negative
ATACS, 1994	warfarin	control (on top of aspirin)				negative
CARS, 1997	warfarin	control (on top of aspirin)				negative
OASIS Pilot (phase 1), 1998	warfarin	control (on top of aspirin)				negative
OASIS Pilot (phase 2), 1998	warfarin	control (on top of aspirin)				negative
OASIS-2 Warfarin Substudy, 2001	warfarin	control (on top of aspirin)				negative
APRICOT-2, 2002	warfarin	control (on top of aspirin)				negative
CHAMP, 2002	warfarin	control (on top of aspirin)				negative
WARIS, 2002	warfarin	control (on top of aspirin)				suggesting
LoWASA, 2004	warfarin	control (on top of aspirin)				negative
Zibaeenezhad, 2004	warfarin	control (on top of aspirin)				negative
Williams, 1997	warfarin	placebo (on top of aspirin)			Low risk of bias	negative
Huyhn, 2001	warfarin	placebo (on top of aspirin)			Low risk of bias	negative
ATACS (pilot study) warfarin vs aspirin, 1990	warfarin	aspirin				negative
ximelagatran
ESTEEM, 2003	ximelagatran	placebo			Exploratory	-
antiplatelets drug
not classified
Jones, 1987	dazoxiben	control				negative
GRAND, 1987	GR3219B	control				negative
Gent-AMI, 1968	misc.	control				negative
Johannessen, 1989	misc.	control				negative
French, 1993	flurbiprofen	placebo			Low risk of bias	suggesting
CURRENT - OASIS 7 (ASA), 2010    NCT	ASA high dose	ASA low dose			Risk of bias	suggesting
aspirin
ATACS-pilot, 1990	aspirin	control				negative
Huddinge, 1988	aspirin	control				negative
Frankfurt, 1976	aspirin	control				negative
VA-pilot	aspirin	placebo				negative
VA-main, 1983	aspirin	placebo			Low risk of bias	suggesting
RISC, 1990	aspirin	placebo			Low risk of bias	suggesting
ALDUSA-pilot	aspirin	placebo				negative
Théroux, 1988	aspirin	placebo			Low risk of bias	suggesting
Canadian (Aspirin vs PBO), 1985	aspirin	placebo			Low risk of bias	-
Dutch-aspirin, 1990	aspirin	placebo			Low risk of bias	negative
ISIS-pilot, 1987	aspirin	placebo			Low risk of bias	negative
ISIS-2, 1988	aspirin	placebo			Low risk of bias	suggesting
APRICOT, 1993	aspirin	placebo			Low risk of bias	suggesting
Canadian (Aspirin + sulfinpyrazone), 1985	aspirin + sulfinpyrazone	placebo			Low risk of bias	negative
atopaxar
J-LANCELOT, 2010	atopaxar	placebo			Exploratory	-
LANCELOT ACS	atopaxar	placebo			Exploratory	-
clopidogrel
COMMIT, 2005      NCT	clopidogrel	placebo			Low risk of bias	suggesting
CLARITY-TIMI 28, 2005	clopidogrel	placebo			Low risk of bias	-
CURE, 2001	clopidogrel + aspirin	aspirin			Low risk of bias	suggesting
CURRENT OASIS 7 (clopidogrel), 2010    NCT	clopidogrel high-dose regimen	clopidogrel standard-dose			Low risk of bias	negative
dipyridamol
Prandoni, 1991	aspirin + dipyridamol	placebo			Low risk of bias	negative
elinogrel
ERASE-MI, 2009	elinogrel	placebo			Low risk of bias	negative
prasugrel
TRILOGY ACS (overall population), 2012        NCT	prasugrel	clopidogrel			Low risk of bias	negative
TRITON-TIMI 38, 2007      NCT	prasugrel	clopidogrel			Low risk of bias	suggesting
sulfinpyrazone
Dutch sulphinpyrazone, 1986	sulfinpyrazone	control				negative
Canadian (sulfinpyrazone alone), 1985	sulfinpyrazone	placebo			Low risk of bias	-
Wilcox, 1980	sulfinpyrazone	placebo				negative
Louvain sulphinpyrazone, 1983	sulfinpyrazone	placebo			Low risk of bias	negative
ticagrelor
PLATO, 2009      NCT	ticagrelor	clopidogrel			Low risk of bias	suggesting
DISPERSE-2 (90mg), 2007	ticagrelor	clopidogrel			Low risk of bias	negative
ticlopidine
STAI, 1990	ticlopidine	control				suggesting
Knudsen-A, 1985	ticlopidine	control				negative
Florida UA	ticlopidine	placebo				negative
trapidil
Modena	trapidil	placebo				suggesting
triflusal
Plaza, 1993	triflusal	placebo			Low risk of bias	suggesting
vorapaxar
TRACER, 2011      NCT	vorapaxar	placebo (on top standard therapy)			Low risk of bias	-
antithrombotics
not classified
Gurfinkel (LMWH+asp vs asp), 1995	LMWH	placebo (on top of aspirin)				suggesting
CURRENT - OASIS 7 (ASA), 2010    NCT	ASA high dose	ASA low dose			Risk of bias	suggesting
Gurfinkel (LMWH+asp vs UFH+asp), 1995	LMWH	UFH (on top of aspirin)				suggesting
apixaban
APPRAISE-1 (10mg od), 2009      NCT	apixaban	placebo			Low risk of bias	negative
APPRAISE-1 (2.5 mg bid), 2009      NCT	apixaban	placebo			Low risk of bias	negative
APPRAISE 2, 2011      NCT	apixaban	placebo			Low risk of bias	negative
argatroban
ARGAMI-2, 1998	Argatroban	heparin				-
aspirin
ATACS-pilot, 1990	aspirin	control				negative
VA-pilot	aspirin	placebo				negative
VA-main, 1983	aspirin	placebo			Low risk of bias	suggesting
RISC, 1990	aspirin	placebo			Low risk of bias	suggesting
ALDUSA-pilot	aspirin	placebo				negative
Théroux, 1988	aspirin	placebo			Low risk of bias	suggesting
Canadian (Aspirin vs PBO), 1985	aspirin	placebo			Low risk of bias	-
Canadian (Aspirin + sulfinpyrazone), 1985	aspirin + sulfinpyrazone	placebo			Low risk of bias	negative
atopaxar
LANCELOT ACS	atopaxar	placebo			Exploratory	-
J-LANCELOT, 2010	atopaxar	placebo			Exploratory	-
bivalirudin
ACUITY (biva alone vs hep+aGP2b3a), 2006      NCT	bivalirudin	heparin + GP2b3a inhibitors			Low risk of bias	suggesting
ACUITY (biva+aGP2b3a vs hep+aGP2b3a), 2006    NCT	bivalirudin + GP2b3a inhibitors	heparin + GP2b3a inhibitors			Low risk of bias	negative
PROTECT-TIMI 30, 2006      NCT	bivalirudin	eptifibatide + heparin			Exploratory	-
HERO, 1997	bivalirudin	heparin			Low risk of bias	suggesting
BAT (Bittl), 1995	bivalirudin	heparin			Low risk of bias	suggesting
ACUITY (sub groups PCI, bivalirudin alone) importé, 2007	bivalirudin	heparin + GP2b3a inhibitors				suggesting
ACUITY (sub groups PCI, bivalirudin +aGP2b3a) importé, 2007	bivalirudin + GP2b3a inhibitors	heparin + GP2b3a inhibitors				negative
clopidogrel
CURE (PCI sub study), 2001	clopidogrel	placebo			Low risk of bias	-
CURE, 2001	clopidogrel + aspirin	aspirin			Low risk of bias	suggesting
CURRENT OASIS 7 (clopidogrel), 2010    NCT	clopidogrel high-dose regimen	clopidogrel standard-dose			Low risk of bias	negative
coumadin
ASPECT-2 (coumadin+asp vs asp), 2002	coumadin	control (on top of aspirin)				suggesting
ASPECT-2 (coumadin vs aspirin), 2002	coumadin	aspirin				suggesting
dalteparin
FRISC (long term), 1996	dalteparin	placebo (on top of aspirin)			Low risk of bias	suggesting
FRIC prolonged treatment phase (LWMH vs PBO), 1997	dalteparin	placebo (on top of aspirin)			Low risk of bias	negative
FRISC (short term), 1996	dalteparin	placebo (on top of aspirin)			Low risk of bias	-
FRIC (acute phase LMWH vs UFH), 1997	dalteparin	UFH (on top of aspirin)			Exploratory	negative
dipyridamol
Prandoni, 1991	aspirin + dipyridamol	placebo			Low risk of bias	negative
Efegatran
Klootwijk, 1999	Efegatran	heparin			Exploratory	-
enoxaparin
RESCUE    NCT	enoxaparin	unfractionated heparin				-
EVET, 2005	enoxaparin	tinzaparin				suggesting
ESSENCE, 1997	enoxaparin	UFH (on top of aspirin)			Low risk of bias	suggesting