Assessment of Pretreatment With Oral P2Y12 Inhibitors and Cardiovascular and Bleeding Outcomes in Patients With Non-ST Elevation Acute Coronary Syndromes

Dawson, L.; Chen, David C.; Dagan, M.; Bloom, Jason; Taylor, Andrew J.; Duffy, Stephen J.; Shaw, James A.; Lefkovits, Jeffrey

doi:10.1001/jamanetworkopen.2021.34322

Cited by 14 publications

(10 citation statements)

References 33 publications

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“…Compared with treatment with aspirin and heparin, treatment with intravenous glycoprotein IIb/IIIa inhibitors was associated with a 1% absolute reduction in 30-day MI or death in patients with NSTE-ACS, particularly in those undergoing PCI, and was associated with a 1% absolute increase in major bleeding . In patients with planned coronary angiography, administration of P2Y12 inhibitors should be withheld until after the coronary anatomy is defined to avoid exposing patients who might need cardiac surgery to the bleeding risks from these medications …”

Section: Treatmentmentioning

confidence: 99%

Diagnosis and Treatment of Acute Coronary Syndromes

Bhatt

Lopes

Harrington

2022

JAMA

255

135

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cute coronary syndromes (ACS) are defined by a sudden reduction in blood supply to the heart and include ST-segmentelevationmyocardialinfarction(STEMI)andnon-ST-segment elevation ACS (NSTE-ACS). NSTE-ACS consists of non-STsegment elevation myocardial infarction (NSTEMI) and unstable angina. [1][2][3][4] Each year, an estimated more than 7 million people are diagnosed with ACS worldwide, including more than 1 million patients hospitalized in the US for ACS. 5,6 Approximately 5% of patients with ACS die before hospital discharge. 2,[5][6][7] Coronary atherosclerotic plaque rupture with thrombus formation accounts for approximately 70% of fatal acute MIs and sudden coronary deaths. 8 This review summa-rizes current evidence regarding epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, and prognosis of ACS (Box). MethodsWe searched PubMed for English-language studies of the epidemiology, pathophysiology, diagnosis, treatment, and prognosis of ACS that were published from January 1, 2000, to January 1, 2022. A total of 1094 articles were retrieved with the search. We manually inspected the reference lists of selected articles for other relevant IMPORTANCE Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart and include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. Each year, an estimated more than 7 million people in the world are diagnosed with ACS, including more than 1 million patients hospitalized in the US.OBSERVATIONS Chest discomfort at rest is the most common presenting symptom of ACS and affects approximately 79% of men and 74% of women presenting with ACS, although approximately 40% of men and 48% of women present with nonspecific symptoms, such as dyspnea, either in isolation or, more commonly, in combination with chest pain. For patients presenting with possible ACS, electrocardiography should be performed immediately (within 10 minutes of presentation) and can distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS). STEMI is caused by complete coronary artery occlusion and accounts for approximately 30% of ACS. ACS without significant ST-segment elevation on electrocardiography, termed NSTE-ACS, account for approximately 70% of ACS, are caused by partial or intermittent occlusion of the artery and are associated with ST-segment depressions (approximately 31%), T-wave inversions (approximately 12%), ST-segment depressions combined with T-wave inversions (16%), or neither (approximately 41%). When electrocardiography suggests STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality from 9% to 7%. If PCI within 120 minutes is not possible, fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose should be administered for patients younger than 75 years without contraindications and at half dose for patients 75 years or older (or streptokinase at full dose if cost is a consideration), followed by tran...

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Section: Treatmentmentioning

confidence: 99%

Diagnosis and Treatment of Acute Coronary Syndromes

Bhatt

Lopes

Harrington

2022

JAMA

255

135

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“… 20 A recent meta-analysis suggests that pretreatment with oral P2Y 12 inhibitors prior to angiography, compared with after knowledge of coronary anatomy at the time of PCI, is associated with no difference in cardiovascular outcomes and with increased bleeding risk, irrespective of the P2Y 12 inhibitor type and, thus, routine pretreatment in NSTE-ACS is not supported. 21 …”

Section: Discussionmentioning

confidence: 99%

“…Following the Comparison of Prasugrel at the Time of Percutaneous Coronary Intervention or as Pretreatment at the Time of Diagnosis in Patients with Non-ST Elevation Myocardial Infarction (ACCOAST) trial, pretreatment with prasugrel, before knowledge of the coronary anatomy, is prohibited because of the lack of any ischaemic benefit and increased risk of bleeding 20. A recent meta-analysis suggests that pretreatment with oral P2Y 12 inhibitors prior to angiography, compared with after knowledge of coronary anatomy at the time of PCI, is associated with no difference in cardiovascular outcomes and with increased bleeding risk, irrespective of the P2Y 12 inhibitor type and, thus, routine pretreatment in NSTE-ACS is not supported 21…”

Section: Discussionmentioning

confidence: 99%

Comparative efficacy and safety of oral P2Y₁₂inhibitors after non-ST-elevation acute coronary syndromes: a network meta-analysis

et al. 2022

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BackgroundCurrently, potent P2Y12 inhibition with the use of prasugrel or ticagrelor is the mainstay of treatment after an acute coronary syndrome (ACS). The 2020 European Society of Cardiology (ESC) Guidelines recommend the use of prasugrel over ticagrelor in patients with non-ST-elevation ACS (NSTE-ACS) intended to receive invasive management (class IIa recommendation), however there are contradictory views regarding this recommendation.AimTo compare oral P2Y12 inhibitors in NSTE-ACS in terms of efficacy and safety with a focus on patients intended to proceed to invasive management.MethodsWe systematically searched PubMed, Cochrane Central Register of Controlled Trials and Web of Science to identify studies that compared different oral P2Y12 inhibitors (clopidogrel, prasugrel and ticagrelor) in patients with NSTE-ACS. Efficacy outcomes included the major adverse cardiovascular events outcome and safety outcomes included minor and major bleedings. We performed a frequentist network meta-analysis.ResultsNine studies (n=35 441 patients) were included in the systematic review. There was no difference between prasugrel and ticagrelor in the composite cardiovascular end point (prasugrel vs ticagrelor HR=0.80, 95% CI=0.61 to 1.06) in all patients with NSTE-ACS. In patients intended to receive invasive management, prasugrel resulted in a reduction of the composite cardiovascular end point both versus clopidogrel (HR=0.76, 95% CI=0.61 to 0.95) and ticagrelor (HR=0.74, 95% CI=0.56 to 0.98). Inconsistency was moderate and non-significant (I2=27%, total Q p=0.2). Prasugrel ranked as the most efficient treatment in the composite cardiovascular efficacy outcome, all-cause death, myocardial infarction and definite stent thrombosis, while clopidogrel ranked as safest in the bleeding outcomes.ConclusionIn patients with NSTE-ACS intended to receive invasive management, an antiplatelet strategy based on prasugrel is more efficient than a similar strategy based on ticagrelor on a moderate level of evidence. This analysis supports the current recommendations by the ESC guidelines.

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“…This strategy may theoretically be associated with reduced risk of early ischemic events such as periprocedural MI, distal coronary embolization and acute ST [47,48]. However, this theoretical advantage comes at the expenses of a certain increase of bleeding [44,49]. Routine P2Y 12 inhibitor pre-treatment is currently recommended by guidelines in STEMI but not in stable patients and NSTEMI, with the indications in the latter setting having undergone drastic changes in the past years [27,32,33].…”

Section: Periprocedural Antiplateletmentioning

confidence: 99%

Bleeding Complications in Patients Undergoing Percutaneous Coronary Intervention

Galli¹,

Laborante²,

Andreotti³

et al. 2022

Rev. Cardiovasc. Med.

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Percutaneous coronary intervention (PCI) is considered a relatively safe procedure associated with low rates of complications, but is inevitably associated with short and mid-to-long term increased bleeding risk. Besides the short term risk associated with the arterial access to perform PCI, enhanced bleeding risk persists for several months, given the need for antithrombotic therapy to prevent procedurerelated thrombotic complications as well as ischemic recurrences. Bleeding is a powerful harbinger of adverse outcomes. This awareness has fuelled intense research on bleeding reduction strategies, including new PCI devices and techniques as well as new medications and antithrombotic regimens. We here review the mechanisms and prevalence of bleeding in PCI patients, discuss the available evidence from a practical point of view, and explore future perspectives on how to treat and prevent bleeding complications in these patients.

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Assessment of Pretreatment With Oral P2Y12 Inhibitors and Cardiovascular and Bleeding Outcomes in Patients With Non-ST Elevation Acute Coronary Syndromes

Cited by 14 publications

References 33 publications

Diagnosis and Treatment of Acute Coronary Syndromes

Diagnosis and Treatment of Acute Coronary Syndromes

Comparative efficacy and safety of oral P2Y₁₂inhibitors after non-ST-elevation acute coronary syndromes: a network meta-analysis

Bleeding Complications in Patients Undergoing Percutaneous Coronary Intervention

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Assessment of Pretreatment With Oral P2Y12 Inhibitors and Cardiovascular and Bleeding Outcomes in Patients With Non-ST Elevation Acute Coronary Syndromes

Cited by 14 publications

References 33 publications

Diagnosis and Treatment of Acute Coronary Syndromes

Diagnosis and Treatment of Acute Coronary Syndromes

Comparative efficacy and safety of oral P2Y12inhibitors after non-ST-elevation acute coronary syndromes: a network meta-analysis

Bleeding Complications in Patients Undergoing Percutaneous Coronary Intervention

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Comparative efficacy and safety of oral P2Y₁₂inhibitors after non-ST-elevation acute coronary syndromes: a network meta-analysis