Open heart · 2026
P2Y12 inhibitor pre-treatment in NSTE-ACS: translating trial evidence into UK clinical practice.
СтатьяНаблюдательное исследованиеНазвание и аннотация: Перевод в очереди
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Hesse Kerrick, Stephens Jessica, Batty Jonathan A, Bayliss Christopher David, Memon Saif, Loh Shu Xian, Telyuk Pyotr, Swanson Neil, Muir Douglas, Jackson Matthew, Carter Justin, Sutton Andrew, Vijayan Sethumadhavan, Williams Paul D, Akowuah Enoch, Wilkinson Chris, Austin David
Аннотация
BACKGROUND: Dual antiplatelet therapy is indicated in the management of non-ST-elevation acute coronary syndrome (NSTE-ACS) and can be administered before coronary angiography (pre-treatment) or after coronary anatomy is known. Based on clinical trials with rapid access to inpatient coronary angiography, clinical guidelines recommend invasive assessment prior to commencing a second antiplatelet. We aimed to evaluate the impact of a change in clinical policy from routine P2Y12 inhibitor pre-treatment to no routine pre-treatment on in-hospital outcomes in a UK healthcare context.
METHODS: A retrospective observational study of hospitalised NSTE-ACS patients with a planned invasive strategy at a tertiary cardiac centre in Northeast England was conducted. Two cohorts were identified: routine pre-treatment (1 January 2021 to 31 December 2021) and no routine pre-treatment (1 July 2022 to 30 June 2023). Primary endpoints were in-hospital ST-elevation myocardial infarction (STEMI) and actionable bleeding events, reported as propensity score-adjusted ORs (ORs) and 95% CIs.
RESULTS: Of 2506 NSTE-ACS cases, 1219 presented before and 1287 after the policy change, which was adhered to in most cases (84.2%). Median time from admission to angiography was 3.6 days (IQR 1.9, 5.8). In comparison to a routine pre-treatment strategy, a no routine pre-treatment strategy was associated with greater risk of in-hospital STEMI (1.7% vs 0.4%, adjusted OR 4.40, 95% CI 1.78 to 13.3), but lower risk of actionable bleeding events (0.2% vs 0.9%, adjusted OR 0.18, 95% CI 0.03 to 0.70). There was evidence of pre-treatment effect modification by procedural waiting time on in-hospital STEMI incidence (p for interaction=0.026).
CONCLUSION: We observed a greater risk of in-hospital STEMI but lower rates of bleeding following the change from a routine pre-treatment to a no routine pre-treatment strategy. UK waiting times for in-patient coronary angiography are typically considerably longer than the trials on which guidance is based, which may impact the risk/benefit balance in clinical practice.
METHODS: A retrospective observational study of hospitalised NSTE-ACS patients with a planned invasive strategy at a tertiary cardiac centre in Northeast England was conducted. Two cohorts were identified: routine pre-treatment (1 January 2021 to 31 December 2021) and no routine pre-treatment (1 July 2022 to 30 June 2023). Primary endpoints were in-hospital ST-elevation myocardial infarction (STEMI) and actionable bleeding events, reported as propensity score-adjusted ORs (ORs) and 95% CIs.
RESULTS: Of 2506 NSTE-ACS cases, 1219 presented before and 1287 after the policy change, which was adhered to in most cases (84.2%). Median time from admission to angiography was 3.6 days (IQR 1.9, 5.8). In comparison to a routine pre-treatment strategy, a no routine pre-treatment strategy was associated with greater risk of in-hospital STEMI (1.7% vs 0.4%, adjusted OR 4.40, 95% CI 1.78 to 13.3), but lower risk of actionable bleeding events (0.2% vs 0.9%, adjusted OR 0.18, 95% CI 0.03 to 0.70). There was evidence of pre-treatment effect modification by procedural waiting time on in-hospital STEMI incidence (p for interaction=0.026).
CONCLUSION: We observed a greater risk of in-hospital STEMI but lower rates of bleeding following the change from a routine pre-treatment to a no routine pre-treatment strategy. UK waiting times for in-patient coronary angiography are typically considerably longer than the trials on which guidance is based, which may impact the risk/benefit balance in clinical practice.
Предметные рубрики MeSH
HumansRetrospective StudiesFemaleMaleCoronary AngiographyPurinergic P2Y Receptor AntagonistsAgedTreatment OutcomeNon-ST Elevated Myocardial InfarctionMiddle AgedAcute Coronary SyndromeUnited KingdomTime FactorsPlatelet Aggregation InhibitorsHemorrhageST Elevation Myocardial InfarctionEnglandRisk Factors