Key result
Omitting routine P2Y12 pre-treatment is linked to ~4-fold higher in-hospital STEMI risk despite less bleeding.
Why the study?
Does a no routine pre-treatment strategy compared to routine P2Y12 inhibitor pre-treatment affect the risk of in-hospital STEMI and actionable bleeding in patients with NSTE-ACS awaiting invasive angiography?
Observational (n=2,506)
No
Does a no routine pre-treatment strategy compared to routine P2Y12 inhibitor pre-treatment affect the risk of in-hospital STEMI and actionable bleeding in patients with NSTE-ACS awaiting invasive angiography?
Odds Ratio: 4.4 (95% CI 1.78–13.3)
Absolute Event Rate: 1.7% vs 0.4%
In healthcare systems with prolonged waiting times for coronary angiography, withholding routine P2Y12 inhibitor pre-treatment in NSTE-ACS reduces bleeding but significantly increases the risk of in-hospital STEMI.
Should not yet change pre-treatment practice in NSTE-ACS; leaves open net benefit pending randomized confirmation.
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 P2Y 12 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.
No takes yet. Share an insight, caveat, or question.
Hesse et al. (2026) conducted an observational in non-ST-elevation acute coronary syndrome (NSTE-ACS) (n=2,506). No routine P2Y12 inhibitor pre-treatment vs. Routine P2Y12 inhibitor pre-treatment was evaluated on In-hospital ST-elevation myocardial infarction (STEMI) (adjusted OR 4.40, 95% CI 1.78 to 13.3). A no routine pre-treatment strategy was associated with a greater risk of in-hospital STEMI (adjusted OR 4.40) but a lower risk of actionable bleeding events compared to routine pre-treatment.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: