European practice patterns for antiplatelet management in NSTE-ACS patients: Results from the REal-world ADoption survey focus on acute antiPlatelet treatment (READAPT) survey

Comparative Profiles and Invasive Management of Patients With High-Risk Non-ST Elevation Acute Coronary Syndromes in Two University Hospitals From Romania and Germany

BACKGROUND

Regional differences in cardiovascular disease (CVD), prevalence, and outcomes in the European population have been reported. Although current European Society of Cardiology guidelines recommend invasive coronary angiography (ICA) <24 hours from diagnosis in high-risk non-ST elevation acute coronary syndromes (NSTE-ACS), overall management remains heterogenous across Europe.

STUDY QUESTION

What are the differences regarding profiles of patients with high-risk NSTE-ACS and factors associated with timing of ICA in 2 university hospitals from 2 European countries with different prevalence of CVD and different income (University and Emergency Hospital, Bucharest, Romania [RO] and University Hospital, Essen, Germany [GER])?

STUDY DESIGN

Retrospective, observational, all-comers.

MEASURES AND OUTCOMES

All consecutive invasively managed patients with high-risk NSTE-ACS in 2022 were retrospectively identified and analyzed regarding clinical profiles and factors associated with ICA timing in relation to the 24-hour European Society of Cardiology recommended interval.

RESULTS

A total of 587 patients were included: 301 from RO and 286 from GER. RO patients were younger (64.6 vs. 70.6 years, P < 0.001), with higher rates of obesity (P = 0.013), hypertension (P = 0.001), dyslipidemia (P < 0.001), diabetes (P < 0.001), and active smoking (P = 0.019), whereas GER patients had higher rates of previous myocardial revascularization (P < 0.001), chronic respiratory disease (P < 0.001), sleep apnea (P < 0.001), thyroid disorders (P < 0.001), and neoplasia (P = 0.036). About 68.1% patients from RO versus 74.8% from GER underwent ICA <24 hours (P = 0.006). Transfers and admission during cathlab on-hours in RO, diagnosis of myocardial infarction, and typical angina in GER were associated with ICA <24 hours (all P < 0.05).

CONCLUSIONS

High-risk NSTE-ACS patient profiles mirrored overall regional CVD patterns. Compared to the German hospital, patients in the Romanian hospital had a worse CVD risk factor profile at a younger age, lower previous myocardial revascularization, and potentially underdiagnosed comorbidities. Health care system organization and hospital logistics largely influenced ICA timing in the Romanian hospital, opposite mainly patient characteristics in the German hospital.

The Association of P2Y12 Inhibitor Pretreatment With Length of Stay Among Patients With Acute Coronary Syndrome Who Underwent Coronary Artery Bypass Graft Surgery: A Cohort Study

Introduction: Recent clinical practice guidelines do not recommend routine P2Y12 inhibitor pretreatment for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) treated with an early invasive strategy based upon clinical trial data suggesting no improvement in clinical outcomes and increased risk of bleeding. A subset of patients with NSTE-ACS who receive pretreatment and subsequently require coronary artery bypass graft (CABG) surgery may require lengthy P2Y12 inhibitor washout to reduce periprocedural bleeding risk, potentially prolonging hospitalization and increasing costs. We sought to study the association of P2Y12 inhibitor pretreatment on value-based outcomes including length of stay, cost, and discharge destination. Methods: We conducted a retrospective cohort study of patients presenting with NSTE-ACS who underwent CABG at a tertiary academic medical center between 2019 and 2021. We assessed the frequency of P2Y12 inhibitor pretreatment over the study period and compared risk-adjusted length of stay, cost of hospitalization, and discharge destination among patients who did or did not receive pretreatment. Results: One hundred eighty-eight patients met inclusion criteria, and 77% received pretreatment. The rate of pretreatment decreased significantly over the study period (p < 0.001). Pretreatment was associated with longer preoperative length of stay (4.2 ± 1.6 vs. 3.4 ± 2.5 days, p = 0.019), with no significant difference in postoperative or total length of stay. There was no difference in cost of hospitalization or likelihood of discharge to home following CABG. Conclusion: Among patients presenting with NSTE-ACS who underwent inpatient CABG, P2Y12 inhibitor pretreatment was associated with longer preoperative length of stay, but no difference in total length of stay, cost of hospitalization, or discharge destination in this observational, single-center study.

P2Y12 Inhibitor Pretreatment in Non-ST-Segment Elevation Acute Coronary Syndrome: The NCDR Chest Pain-MI Registry

BACKGROUND

Although high rates of P2Y12 inhibitor pretreatment (defined as the administration before coronary angiography) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) have been reported, contemporary U.S. practice patterns are not well studied.

OBJECTIVES

The goal of this study was to investigate the temporal U.S. trends, variability, and clinical outcomes of P2Y12 inhibitor pretreatment in NSTE-ACS.

METHODS

Consecutive patients who underwent early invasive strategy for NSTE-ACS (coronary angiography ≤24 hours of arrival) in the National Cardiovascular Data Registry Chest Pain-Myocardial Infarction (MI) Registry were analyzed. A time-trend analysis was conducted on a complete cohort between January 1, 2013, and March 31, 2023. Subsequently, a more recent cohort (January 1, 2019, to March 31, 2023) with a complete set of variables was used to construct hierarchical regression models to quantify the variability in the use of pretreatment among operators and institutions. For this contemporary cohort, instrumental variable analysis, with operator preference as the instrument, was performed to compare the in-hospital outcomes between patients who received pretreatment and those who did not.

RESULTS

Use of P2Y12 inhibitor pretreatment decreased from 24.8% in 2013Q1 to 12.4% in 2023Q1. Among the contemporary cohort of 110,148 patients (2019-2023; mean age 63.9 ± 12.5 years; 33.0% female), 17,509 (15.9%) received pretreatment. Significant variability in P2Y12 inhibitor pretreatment was observed (range: 0%-100%): hierarchical regression model demonstrated that 2 similar patients would have a >3-fold difference in the odds of pretreatment from 1 random operator or institution as compared with another (median OR: 3.74 [95% CI: 3.57-3.91] and 3.63 [95% CI: 3.51-3.74], respectively). Instrumental variable analysis demonstrated no significant differences in in-hospital all-cause death (1.5% vs 1.7%; P = 0.07), recurrent MI (0.6% vs 0.6%; P = 0.98), or major bleeding (2.7% vs 2.8%; P = 0.98) with pretreatment. However, in patients who underwent coronary artery bypass surgery, pretreatment was associated with a longer length of stay (11.2 ± 5.1 days vs 9.8 ± 5.0 days; P < 0.01).

CONCLUSIONS

In a national U.S. registry, we observed significant variability in the use of P2Y12 inhibitor pretreatment among NSTE-ACS patients. Given the lack of clear advantages and the potential for prolonged hospital stays, our findings highlight the importance of efforts to improve standardization.

ICARUS score for predicting peri-procedural bleeding in patients undergoing percutaneous coronary intervention with cangrelor

BACKGROUND

Tools for precise prediction of bleeding risk in patients undergoing percutaneous coronary intervention (PCI) with cangrelor are lacking.

METHODS

Consecutive patients undergoing PCI and treated with cangrelor in 7 centers were retrospectively enrolled. The primary endpoint was Bleeding Academic Research Consortium (BARC) BARC 2, 3, or 5 bleeding 48 h after PCI. Predictors of BARC 2-5 bleeding were identified in a derivation cohort and combined into a numerical risk score. Discrimination and calibration were assessed in the derivation and validation cohorts. A threshold to define high bleeding risk (HBR) was identified and its diagnostic accuracy was compared with that of currently recommended bleeding risk scores.

RESULTS

1071 patients undergoing PCI with cangrelor were included. Fifty-four patients (5 %) experienced a BARC 2-5 bleeding, of whom 24 (44 %) from the access site. Age ≥ 75 years (odds ratio [OR] 2.58, 95 % confidence interval [CI] 1.21-5.48, p = 0.01), acute coronary syndrome at presentation (OR 8.14, 95 % CI 2.28-52, p = 0.01), and femoral access (OR 6.21, 95 % CI 2.71-14, p < 0.001) independently predicted BARC 2-5 bleeding at 48 h after PCI. The three items were combined to form a new risk score, the ICARUS score, showing good discrimination in both the derivation (area under the curve [AUC] 0.78) and internal validation (AUC 0.77) cohorts, and excellent calibration. An ICARUS score > 9 points accurately identified patients at HBR, showing better discrimination than other risk scores.

CONCLUSIONS

A risk score based on age, clinical presentation and access site, predicts the risk of periprocedural bleeding in patients receiving cangrelor (ClinicalTrials.gov ID: NCT05505591).

The Evolving Field of Acute Coronary Syndrome Management: A Critical Appraisal of the 2023 European Society of Cardiology Guidelines for the Management of Acute Coronary Syndrome

Acute coronary syndromes (ACS), encompassing conditions like ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndromes (NSTE-ACS), represent a significant challenge in cardiovascular care due to their complex pathophysiology and substantial impact on morbidity and mortality. The 2023 European Society of Cardiology (ESC) guidelines for ACS management introduce several updates in key areas such as invasive treatment timing in NSTE-ACS, pre-treatment strategies, approaches to multivessel disease, and the use of imaging modalities including computed tomography (CT) coronary angiography, magnetic resonance imaging (MRI), and intracoronary imaging techniques, such as optical coherence tomography (OCT) and intravascular ultrasound (IVUS). They also address a modulation of antiplatelet therapy, taking into consideration different patient risk profiles, and introduce new recommendations for low-dose colchicine. These guidelines provide important evidence-based updates in practice, reflecting an evolution in the understanding and management of ACS, yet some potentially missed opportunities for more personalized care and technology adoption are discussed.