Precatheterization Use of P2Y12 Inhibitors in Non-ST-Elevation Myocardial Infarction Patients Undergoing Early Cardiac Catheterization and In-Hospital Coronary Artery Bypass Grafting: Insights From the National Cardiovascular Data Registry®

P2Y12 adenosine receptor inhibitors preloading among patients with non-ST-elevation acute coronary syndromes; insights from a nationwide multicenter registry

BACKGROUND

The safety and efficacy of treatment with P2Y12 adenosine-diphosphate receptor inhibitors (P2Y12-RI) before coronary angiography among patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) are questionable.

AIMS

To assess the pretreatment rate with P2Y12-RI and its association with ischemic and bleeding risks among patients with NSTEACS.

METHODS

The study comprised patients with NSTEACS referred for coronary angiography and included in the Acute Coronary Syndrome Israeli Surveys between 2013 and 2021. Patients were divided into two groups according to the timing of P2Y12-RI loading concerning coronary angiography: pretreatment and posttreatment. The primary endpoints were 30-day major adverse cardiovascular events (MACE; composite of cardiovascular mortality, myocardial infarction, stroke, stent thrombosis, and urgent revascularization) and 1-year all-cause mortality.

RESULTS

Of 3076 patients, 2423 (78.8%) received pretreatment with a P2Y12-RI, and 653 (21.2%) received P2Y12-RI posttreatment. Prasugrel and ticagrelor were used more in the posttreatment group compared to the pretreatment group (16% vs. 6% and 38% vs. 25%, respectively, p < 0.001 for both). No difference was observed in the rate of 30-day MACE comparing pretreatment and posttreatment (5.3% vs. 2.2%, respectively, p = 0.62). A sensitivity analysis of 30-day MACE among patients from the 2021 survey demonstrated similar results (2.5% in the posttreatment group vs. 8.0% in the pretreatment group, p = 0.13). There were no differences in 1-year all-cause mortality rates between the pretreatment and posttreatment groups (4.8% vs. 3.8%, p = 0.31).

CONCLUSIONS

Among patients with NSTEACS referred for an invasive strategy, the P2Y12-RI posttreatment strategy was associated with similar 30-day and 1-year MACE as the pretreatment strategy. These large-scale, multicenter, real-world data provide reassurance on the safety and efficacy of delaying P2Y12-IR until after coronary stratification to improve clinical decision-making.

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

BACKGROUND

The 2020 European Society of Cardiology (ESC) guidelines for the diagnosis and management of patients with non-ST elevation-acute coronary syndrome (NSTE-ACS) recommend early invasive coronary angiography in high-risk patients and no routine pre-treatment with oral P2Y12 receptor inhibitor in NSTE-ACS patients prior to defining coronary anatomy.

OBJECTIVE

To assess the implementation of this recommendation in the real-life setting.

METHODS

A web-survey in 17 European countries collected physician profiles and their perceptions of the diagnosis, medical and invasive management of NSTE-ACS patients at their hospital. A sample size of at least 1100 responders permitted the estimation of proportions with a precision of at least ±3.0%.

RESULTS

Among the 3024 targeted participants, 1154 provided valid feedback defined as a 50% response rate of answers to the survey questions. Overall, >60% of the participants declared full implementation of the guidelines at their institution. The time delay from admission to coronary angiography and PCI was reported to be <24 h in over 75% of the hospitals while pre-treatment was intended in >50% of NSTE-ACS patients. Ad-hoc percutaneous coronary intervention (PCI) was performed in >70% of the cases while intravenous platelet inhibition was rarely used (<10%). Between countries differences in practice patterns for antiplatelet management for NSTE-ACS were observed, suggesting heterogeneous implementation of the guidelines.

CONCLUSIONS

This survey indicates that the implementation of 2020 NSTE-ACS guidelines on early invasive management and pre-treatment is heterogeneous, potentially due by local logistical constraints.

Cost-Consequence Analysis of Using Cangrelor in High Angiographic Risk Percutaneous Coronary Intervention Patients: A US Hospital Perspective

OBJECTIVES

The objective of this study was to evaluate a US hospital's cost implications and outcomes of cangrelor use in percutaneous coronary intervention (PCI) patients with two or more angiographic high-risk features (HRFs), including avoidance of oral P2Y₁₂ inhibitor pretreatment in patients requiring cardiac surgery. Intravenous cangrelor provides direct, immediate onset and rapid-offset P2Y₁₂ inhibition, which may reduce the necessity for oral P2Y₁₂ pretreatment.

METHODS

A decision analytic model was developed, estimating the annual impact over 3 years of cangrelor availability. Ischemic and bleeding events (48 h) from randomized clinical trial data were extrapolated to 30 days. Event costs were from the CHAMPION PHOENIX Economics substudy. Rates of coronary artery disease (CAD) presentation, PCI, oral P2Y₁₂ pretreatment, and inpatient hospitalization costs were from published literature and clinical experts. Scenario analyses evaluated the impact of cangrelor availability on potential reduced P2Y₁₂ pretreatment rates by 50-100%. Drug costs were 2019 wholesale acquisition costs and, where necessary, all costs were adjusted to 2019 dollars.

RESULTS

In a hospital treating 1000 CAD PCI inpatients annually, increasing cangrelor use from 11 to 32% resulted in a reduction in 48-h ischemic events/year by 5.7%, while bleeding events increased by 2.9%. Total costs of $1,135,472 declined 12.8%, with a 50% reduction in P2Y₁₂ pretreatment or 30% with no pretreatment. Savings were driven by a decrease in ischemic events, decrease in glycoprotein IIb/IIIa inhibitor use, and less need for and shorter oral P2Y₁₂ inhibitor washout period for surgery patients.

CONCLUSION

Use of cangrelor in patients with two or more angiographic HRFs may improve outcomes and lower hospital budgets, mainly from avoiding surgery delays necessitated by oral P2Y₁₂ inhibitor pretreatment.

Outcome of acute myocardial infarction versus stable coronary artery disease patients treated with coronary bypass surgery

OBJECTIVE

To study the long-term outcome differences between acute myocardial infarction (MI) and stable coronary artery disease (CAD) patients treated with coronary artery bypass grafting (CABG).

METHODS

We studied retrospectively patients with MI (n = 1882) or stable CAD (n = 13117) treated with isolated CABG between 2004 and 2014. Inverse propensity probability weight adjustment for baseline features was used. Median follow-up was 7.9 years.

RESULTS

In-hospital mortality (8.6% vs. 1.6%; OR 5.94; p < .0001) and re-sternotomy (5.5% vs. 2.7%; OR 2.07; p < .0001) were more common in MI patients compared to stable CAD patients. Hospital surviving MI patients had higher all-cause mortality (28.2% vs. 22.2%; HR 1.37; p = .002) and MACE rate (34.4% vs. 27.4%; HR 1.22; CI 1.00-1.50; p = .049) at 10-year follow-up. Cardiovascular mortality (15.9% vs. 12.7%; HR 1.36; p = .017) and rate of new myocardial infarction (12.0% vs. 9.8%; HR 1.40; p = .034) were also higher in MI patients during follow-up. In follow-up of stabilized first-year survivors, the difference in all-cause (26.5% vs. 20.7%; HR 1.40; p = .003) and cardiovascular (14.2% vs. 11.4%; HR 1.37; p = .027) mortality continued to increase between MI and stable CAD patients.

CONCLUSION

MI patients have poorer short- and long-term outcomes compared to stable CAD patients after CABG and risk difference continues to increase with time. Key Messages Patients with myocardial infarction have poorer short- and long-term outcomes compared to stable coronary artery disease patients after coronary artery bypass grafting (CABG). Higher risk of death continues also in stabilized first-year myocardial infarct survivors. The importance of efficient secondary prevention and follow-up highlights in post-myocardial infarct population after CABG.

Assessment of Pretreatment With Oral P2Y12 Inhibitors and Cardiovascular and Bleeding Outcomes in Patients With Non-ST Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis

IMPORTANCE

The practice of pretreatment with oral P2Y12 inhibitors in non-ST elevation acute coronary syndromes (NSTEACS) remains common; however, its association with improved cardiovascular outcomes is unclear.

OBJECTIVE

To assess the association between oral P2Y12 inhibitor pretreatment and cardiovascular and bleeding outcomes in patients with NSTEACS.

DATA SOURCES

On March 20, 2021, PubMed, MEDLINE, Embase, Scopus, Web of Science, Science Direct, clinicaltrials.gov, and the Cochrane Central Register for Controlled Trials were searched from database inception.

STUDY SELECTION

Randomized clinical trials of patients with NSTEACS randomized to either oral P2Y12 inhibitor pretreatment (defined as prior to angiography) or no pretreatment (defined as following angiography, once coronary anatomy was known) among patients undergoing an invasive strategy.

DATA EXTRACTION AND SYNTHESIS

This study followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data on publication year, sample size, clinical characteristics, revascularization strategy, P2Y12 inhibitor type and dosage, time from pretreatment to angiography, and end point data were independently extracted by 2 authors. A random-effects model was used, including stratification by (1) P2Y12 inhibitor type, (2) revascularization strategy, and (3) access site.

MAIN OUTCOMES AND MEASURES

The primary end point was 30-day major adverse cardiac events (MACEs). Secondary end points were 30-day myocardial infarction (MI) and cardiovascular death. The primary safety end point was 30-day major bleeding (defined according to individual studies).

RESULTS

A total of 7 trials randomizing 13 226 patients to either pretreatment (6603 patients) or no pretreatment (6623 patients) were included. The mean age of patients was 64 years and 3598 (27.2%) were female individuals. Indication for P2Y12 inhibitors was non-ST elevation myocardial infarction in 7430 patients (61.7%), radial access was used in 4295 (32.6%), and 10 945 (82.8%) underwent percutaneous coronary intervention. Pretreatment was not associated with a reduction in 30-day MACE (odds ratio [OR], 0.95; 95% CI, 0.78-1.15; I2 = 28%), 30-day MI (OR, 0.90; 95% CI, 0.72-1.12; I2 = 19%), or 30-day cardiovascular death (OR, 0.79; 95% CI, 0.49-1.27; I2 = 0%). The risk of 30-day major bleeding was increased among patients who underwent pretreatment (OR, 1.51; 95% CI, 1.16-1.97; I2 = 41%). The number needed to harm to bring about 1 major bleeding event with oral P2Y12 inhibitor pretreatment was 63 patients.

CONCLUSIONS AND RELEVANCE

In this study, pretreatment with oral P2Y12 inhibitors among patients with NSTEACS prior to angiography, compared with treatment once coronary anatomy is known, was associated with increased bleeding risk and no difference in cardiovascular outcomes. Routine pretreatment with oral P2Y12 inhibitors in patients with NSTEACS receiving an early invasive strategy is not supported by this study.

Ticagrelor Utilization in Patients With Non-ST Elevation Acute Coronary Syndromes in Romania

BACKGROUND

Dual antiplatelet therapy (DAPT) represents a major tool of non-ST elevation acute coronary syndrome (NSTE-ACS) management. The real-world usage of potent P2Y12 inhibitors within DAPT in middle-income countries is poorly described.

STUDY QUESTION

To assess the factors that influence P2Y12 inhibitor choice at discharge in invasively managed NSTE-ACS patients, without an indication for oral anticoagulation, treated across Romania.

STUDY DESIGN

The Romanian National NSTE-ACS Registry allows the consecutive enrollment of NSTE-ACS patients admitted in 11 (of 24) interventional centers reimbursed from public funds.

MEASURES AND OUTCOMES

NSTE-ACS patients that received DAPT at discharge were identified. Deceased patients, those with an indication for oral anticoagulation or not receiving DAPT at discharge, were excluded. P2Y12 inhibitor choice was analyzed based on demographic, clinical, and invasive management characteristics.

RESULTS

One thousand fifty (63 ± 10 years, 73% male) of 1418 patients enrolled between 2016 and 2019 were analyzed. The P2Y12 inhibitor pretreatment rate was 90%. Obstructive coronary artery disease was found in 95.3% of patients. 84.6% underwent percutaneous coronary interventions (PCIs). Single vessel PCI was reported in 84% of PCI patients. The clopidogrel usage rate was 49.6%, ticagrelor 50.0%, and prasugrel 0.4%. Overall, higher ticagrelor usage was associated with: non-ST elevation myocardial infarction (P 0.035), age below 65 (P < 0.001), prior treatment with ticagrelor (P < 0.001), PCI during admission (P < 0.001), and its full 12-month reimbursement (since November 2017). Reimbursement increased the use of ticagrelor from 23.7% in 2016-2017 to 56.9% in 2018-2019 (P < 0.001). In PCI patients, ticagrelor use was associated with PCI with stenting (P 0.016) and multivessel PCI (0.013).

CONCLUSIONS

DAPT, P2Y12 inhibitor pretreatment, and single vessel PCI are the standards of care in invasively managed NSTE-ACS patients in Romania. Besides the clinical and invasive characteristics that favor its use, the full reimbursement of ticagrelor introduced in November 2017 doubled its yearly usage.

Oral Antiplatelet Therapy Administered Upstream to Patients With NSTEMI

To describe from a noninterventional registry (Utilization of Ticagrelor in the Upstream Setting for Non-ST-Segment Elevation Acute Coronary Syndrome), the short-term ischemic and hemorrhagic outcomes in patients with non-ST elevation myocardial infarction (MI) are managed with a loading dose (LD) of a P2Y₁₂ inhibitor (P2Y₁₂i) given at least 4 hours before diagnostic angiography and delineation of coronary anatomy. Prior data on the effects of such “upstream loading” have been inconsistent.

P2Y12 inhibitors for the treatment of acute coronary syndrome patients undergoing percutaneous coronary intervention: current understanding and outcomes

Introduction: Inhibition of P2Y₁₂ platelet receptors consists a crucial target of pharmacologic treatment in acute coronary syndrome patients. Several controversial issues however still remain and these are analyzed.Areas covered: The significance of early and strong platelet inhibition in the early phase of STEMI and the role of pretreatment are discussed. Concerns regarding morphine administration are raised. The role of crushing integral tablets to expedite the onset of action of oral P2Y₁₂ inhibitors is emphasized. New data on the intravenous cangrelor are reported. Antiplatelet therapies as adjunct to thrombolysis, as well as the role of de-escalation antiplatelet therapy are analyzed.Expert opinion: Pharmacodynamic studies convincingly demonstrate a gap in the onset of antiplatelet action in STEMI cases, even when prasugrel or ticagrelor loading dose is used. The clinical benefit, however, of the early platelet inhibition and pretreatment is not entirely clear. Morphine delays the onset of action of oral agents, while this is expedited by crushing the integral tablets. Cangrelor devoids of these deficiencies by achieving fast and strong platelet inhibition in all clinical scenarios. Concomitant administration of novel antiplatelet agents with thrombolysis and de-escalation of antiplatelet treatment necessitate further study to reach definite conclusion.