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Pretreatment With P2Y12 Receptor Antagonists in NSTE-ACS
Quick Takes
- Pretreatment with P2Y12 receptor antagonists was not associated with improved survival or with a lower likelihood of definite stent thrombosis among patients undergoing PCI for NSTE-ACS.
- Furthermore, pretreatment with P2Y12 receptor antagonists was associated with a higher risk of bleeding and the change in the practice from routine pretreatment to no pretreatment was associated with decreased risk of bleeding.
Study Questions:
What is the association of P2Y12 receptor antagonist pretreatment versus no pretreatment with mortality, stent thrombosis, and in-hospital bleeding in patients with non–ST-segment elevation acute coronary syndrome (NSTE-ACS) undergoing percutaneous coronary intervention (PCI)?
Methods:
The investigators 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–June 2019. The primary endpoint was all-cause mortality within 30 days. Secondary endpoints were 1-year mortality, stent thrombosis within 30 days, and in-hospital bleeding.
Results:
In total, 64,857 patients (mean [standard deviation] 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 1,148 (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% confidence interval [CI], 0.66-2.11; p = 0.58), survival at 1 year (OR, 1.34; 95% CI, 0.77-2.34; p = 0.30), or decreased stent thrombosis (OR, 0.81; 95% CI, 0.42-1.55; p = 0.52). However, pretreatment was associated with increased risk of in-hospital bleeding (OR, 1.49; 95% CI, 1.06-2.12; p = 0.02).
Conclusions:
The authors concluded 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.
Perspective:
This cohort study reports that pretreatment with P2Y12 receptor antagonists was not associated with improved survival or with a lower likelihood of definite stent thrombosis among patients undergoing PCI for NSTE-ACS. Furthermore, pretreatment with P2Y12 receptor antagonists was associated with a higher risk of bleeding and the change in the practice from routine pretreatment to no pretreatment was associated with decreased risk of bleeding. These and the randomized ACCOAST and ISAR-REACT 5 trial data suggest that pretreatment may be associated with more harm than benefit in the modern clinical era.
Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Angioplasty, Coronary Angiography, Hemorrhage, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Purinergic P2Y Receptor Antagonists, Secondary Prevention, Stents, Thrombosis
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