Abstract
Pretreatment of patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) with P2Y12 receptor antagonists is a common practice despite the lack of definite evidence for its benefit. To investigate the association of P2Y12 receptor antagonist pretreatment vs no pretreatment with mortality, stent thrombosis, and in-hospital bleeding in patients with NSTE-ACS undergoing percutaneous coronary intervention (PCI). This cohort study used prospective data from the Swedish Coronary Angiography and Angioplasty Registry of 64 857 patients who underwent procedures between 2010 and 2018. All patients who underwent PCI owing to NSTE-ACS in Sweden were stratified by whether they were pretreated with P2Y12 receptor antagonists. Associations of pretreatment with P2Y12 receptor antagonists with the risks of adverse outcomes were investigated using instrumental variable analysis and propensity score matching. Data were analyzed from March to June 2019. Pretreatment with P2Y12 receptor antagonists. The primary end point was all-cause mortality within 30 days. Secondary end points were 1-year mortality, stent thrombosis within 30 days, and in-hospital bleeding. In total, 64 857 patients (mean [SD] age, 64.7 [10.9] years; 46 809 [72.2%] men) were included. A total of 59 894 patients (92.4%) were pretreated with a P2Y12 receptor antagonist, including 27 867 (43.7%) pretreated with clopidogrel, 34 785 (54.5%) pretreated with ticagrelor, and 1148 (1.8%) pretreated with prasugrel. At 30 days, there were 971 deaths (1.5%) and 101 definite stent thromboses (0.2%) in the full cohort. Pretreatment was not associated with better survival at 30 days (odds ratio [OR], 1.17; 95% CI, 0.66-2.11; P = .58), survival at 1 year (OR, 1.34; 95% CI, 0.77-2.34; P = .30), or decreased stent thrombosis (OR, 0.81; 95% CI, 0.42-1.55; P = .52). However, pretreatment was associated with increased risk of in-hospital bleeding (OR, 1.49; 95% CI, 1.06-2.12; P = .02). This cohort study found that pretreatment of patients with NSTE-ACS with P2Y12 receptor antagonists was not associated with improved clinical outcomes but was associated with increased risk of bleeding. These findings support the argument that pretreatment with P2Y12 receptor antagonists should not be routinely used in patients with NSTE-ACS.
Highlights
Administration of P2Y12 receptor antagonists to patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) has been supported by the European Society of Cardiology guidelines for many years[1] and is a common practice despite the lack of definite evidence for its benefit
Pretreatment was not associated with better survival at 30 days, survival at 1 year (OR, 1.34; 95% CI, 0.77-2.34; P = .30), or decreased stent thrombosis (OR, 0.81; 95% CI, 0.42-1.55; P = .52)
This cohort study found that pretreatment of patients with NSTE-ACS with P2Y12 receptor antagonists was not associated with improved clinical outcomes but was associated with increased risk of bleeding
Summary
Administration of P2Y12 receptor antagonists to patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) has been supported by the European Society of Cardiology guidelines for many years[1] and is a common practice despite the lack of definite evidence for its benefit. The only randomized clinical trial to our knowledge in patients with NSTE-ACS found that pretreatment with a P2Y12 receptor antagonist (ie, prasugrel) was not beneficial and that pretreatment was harmful, owing to increased risk of major bleeding.[10] The most recent European Society of Cardiology guidelines from 2015 state, “As the optimal timing of ticagrelor or clopidogrel administration in NSTE-ACS patients scheduled for an invasive strategy has not been adequately investigated, no recommendation for or against pretreatment with these agents can be formulated,” and “based on the ACCOAST results, pretreatment with prasugrel is not recommended.”[11] In this report based on a nationwide, large prospective cohort of patients with NSTE-ACS undergoing percutaneous coronary intervention (PCI) in Sweden, we compared the associations of P2Y12 receptor antagonists pretreatment vs no pretreatment with mortality, stent thrombosis, and bleeding
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