Administration of a thienopyridine in the emergency department (ED) to patients with NSTEMI is not associated with in-hospital mortality or major bleeding complications, according to a study published May 22 in the American Journal of Emergency Medicine.

Additional Resources Full Study ACTION Registry® - GWTG™ 2012 ACCF/AHA Focused Update Incorporated Into the 2007 Guidelines for the Management of Patients With Unstable Angina/NSTEMI

The study used data from the NCDR's ACTION Registry® - GWTG™, and analyzed outcomes of 39,454 patients with NSTEMI who received a thienopyridine within 24 hours of ED presentation. Almost one-quarter of patients (24.2 percent) received a thienopyridine in the ED and the remaining patients received one after hospital admission. Results showed that in the multivariate analysis, ED administration was not associated with in-hospital major bleeding (multivariable adjusted odds ratio, 0.99; 95% confidence interval, 0.91-1.09) or in-hospital mortality (adjusted 1.02; 95% confidence interval, 0.86-1.20). However, although ED thienopyridine use was low, high-risk patients were appropriately identified for ED thienopyridine administration.

"Ischemic ECG changes, higher troponin elevations and longer ED length of stay were associated with ED thienopyridine administration," note the authors. "Despite current guidelines recommending thienopyridine administration as soon as possible in high-risk patients in whom an invasive strategy is planned, most EDs (>75 percent) administer thienopyridine less than one-third of the time. The result is that … only a quarter of patients with NSTEMI receive it in the ED." However, patients with objective findings of acute coronary syndromes in the ED and without complicating factors were most likely to receive a thienopyridine in the ED. "Thus, patients at highest risk for cardiac ischemia were appropriately identified for ED thienopyridine administration," they add.

Moving forward, they note that "to improve the likelihood that guidelines contain evidence-based recommendations relevant to upstream management of patients, studies need to be specifically designed to determine the role of ED medical management and to address outcomes other than mortality, such as recurrent ischemia or reinfarction."

Keywords: Odds Ratio, Acute Coronary Syndrome, Multivariate Analysis, Hospital Mortality, Pyridines, Confidence Intervals, Electrocardiography, Hemorrhage, United States, Troponin

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