Pharmacogenetic-guided antiplatelet therapy for personalized medicine in patients with stroke and transient ischemic attack without cardioembolic stroke: A systematic review of economic evaluations
Bibliographic record
Abstract
Background: Stroke is a major global public health burden. Ischemic stroke is the most common type of all stroke cases worldwide. Antiplatelet therapy is a key strategy for secondary prevention in patients with stroke and transient ischemic attacks (TIAs) without cardioembolic stroke. Dual antiplatelet therapy (DAPT) with clopidogrel is recommended in patients with early mild stroke or high-risk TIA, followed by long-term single antiplatelet therapy (SAPT). Clopidogrel is often used as an alternative for patients with aspirin resistance or intolerance. However, clopidogrel is a prodrug metabolized by the CYP2C19 enzyme, leading to variability in its effectiveness. Objectives: This study aims to review and summarize the economic evaluations of pharmacogenetic (PGx)-guided antiplatelet therapy in patients with stroke and TIA without cardioembolic stroke. Methods: A systematic literature search of PubMed, ScienceDirect, Scopus, Cochrane Review, Tufts CEA (CEA registry), and PharmGKB from their inception to June 30, 2024. Quality assessment was done using the ECOBIAS tool. The synthesis of evidence was based on incremental cost-effectiveness ratio and incremental net benefit, adjusted to 2023 USD values by the consumer price index. Results: The search identified 5,843 articles, of which six studies were eligible. Five studies assessed DAPT, whereas one focused on SAPT for recurrent stroke prevention. PGx-guided therapy with alternative antiplatelet agents (dipyridamole, cilostazol, or ticagrelor) was compared to standard clopidogrel therapy. In the SAPT, PGxguided therapy was more costly but provided more QALYs in Asian populations (Chinese, Indian, and Malaysian). In Canada, Singapore, and China, PGx-guided DAPT was more cost-effective, whereas in the UK, PGx-guided dipyridamole was cost-saving. Conclusion: PGx-guided DAPT with cilostazol, ticagrelor, or clopidogrel can be cost-effective or cost-saving compared to universal clopidogrel. PGx-guided SAPT with ticagrelor in patients with loss-of-function polymorphisms and normal metabolizers may also be cost-effective, though the evidence is of low certainty.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.004 | 0.000 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.004 | 0.001 |
| Bibliometrics | 0.000 | 0.000 |
| Science and technology studies | 0.000 | 0.001 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.000 | 0.000 |
| Research integrity | 0.000 | 0.000 |
| Insufficient payload (model declined to judge) | 0.000 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".