Abstract 12079: Initial Report From an Emergency-Department-Based Registry of NSTEMI Patients Given Upstream Advanced Oral Antiplatelet Therapy

Abstract

Introduction: There are scant data on use of P2Y12 antagonist therapy upstream of diagnostic angiography (DA), especially when administered in the emergency department (ED) for NSTEMI. We are conducting a multicenter registry to describe patterns of upstream P2Y12 antagonist use and outcomes. Methods: UPSTREAM (NCT02271022) is an ongoing US multicenter, prospective, non-interventional registry of consecutive NSTEMI patients, evaluated in an ED, who are given a loading dose (LD) of ticagrelor, clopidogrel, or prasugrel ≥4h prior to DA, with DA performed ≤72h after ED arrival. All patients are followed to hospital discharge. Patients receiving ticagrelor throughout the index hospitalization and at discharge are also followed for vital status, rehospitalization, bleeding complications, and P2Y12 compliance at 30 days post-discharge. Results: We report in-hospital outcomes of the first 578 patients to have data entry completed at 24 US hospitals. Upstream P2Y12 LD was clopidogrel in 60%, ticagrelor in 39%, and prasugrel in 1%. Of these, 234 (40%) received at least one dose of ticagrelor; 116 (20.1%) were ticagrelor-consistent and had follow-up completed. One-fifth of patients were transferred to an UPSTREAM hospital. Mean age was of the poverall sample was 63 years with 19% older than 75. Approximately 23% of patients had a documented prior MI, 31% had at least one prior stent, and 16% had prior CABG. Chest pain was not part of presenting symptoms in 15%. The median (+/-IQR) time from first ED arrival to LD was 6.7h (+/- 6.8 h); time from LD to DA was 12h (+/- 9.6 h). DA was performed via femoral access in 66% of patients and radially in 34%. Post-DA management was 55% stent, 9% CABG, and 35% medical management. In-hospital CV events (0.7%), including mortality, were infrequent. Only 14 patients (6 [1.0%] CABG-related and 8 non-CABG patients [1.4%]) required RBC transfusion, while 8 (6 CABG-related) required a platelet transfusion. One stent thrombosis event was recorded. Conclusions: Upstream P2Y12 therapy in NSTEMI patients undergoing an invasive strategy is associated with good clinical outcomes and minimal risk of bleeding complications. The most commonly used upstream P2Y12 LD was clopidogrel, but in-hospital switching was common. Updated data will be shown.