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ED administration of thienopyridines in non-ST-segment elevation myocardial infarction: results from the NCDR
Deborah B Diercks1, Michael C Kontos, Judd E Hollander
1Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA, USA.
Insights
Administering thienopyridines in the emergency department (ED) for non-ST-segment elevation myocardial infarction (NSTEMI) showed no link to increased bleeding or mortality. ED thienopyridine use was associated with elevated troponin and longer ED stays.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Outcomes Research
Background:
- Current guidelines recommend dual antiplatelet therapy for non-ST-segment elevation myocardial infarction (NSTEMI) but do not specify emergency department (ED) administration timing.
- Investigating the impact of early thienopyridine administration in the ED is crucial for optimizing patient care pathways.
Purpose of the Study:
- To determine if emergency department (ED) administration of a thienopyridine is associated with clinical outcomes in patients diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI).
Main Methods:
- A retrospective analysis of 39,454 patients with NSTEMI who received a thienopyridine within 24 hours of presentation was conducted using the National Cardiovascular Data Registry.
- Patients managed conservatively or with missing time data were excluded. The association between ED thienopyridine administration and in-hospital outcomes was analyzed.
Main Results:
- Of the patients receiving a thienopyridine within 24 hours, 24.2% received it in the ED.
- ED administration of thienopyridines was not associated with increased in-hospital major bleeding or mortality.
- Elevated troponin, longer ED length of stay, prior percutaneous coronary intervention, and ischemic electrocardiogram changes predicted ED thienopyridine administration.
Conclusions:
- Emergency department administration of thienopyridines in NSTEMI patients is not linked to adverse in-hospital outcomes like major bleeding or mortality.
- Factors such as elevated troponin levels and ED length of stay are associated with the timing of thienopyridine administration.
Objective:
American Heart Association/American College of Cardiology guidelines recommend that patients with definite unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI) receive dual antiplatelet therapy on presentation to the hospital when undergoing early invasive management or "as soon as possible" after admission when being managed conservatively. The guidelines do not specify whether these medications should be administered in the emergency department (ED). Our aim was to determine whether ED administration of a thienopyridine was associated with clinical outcomes among patients with NSTEMI.
Methods:
We examined thienopyridine use in 39454 patients with NSTEMI who received a thienopyridine within 24 hours of presentation in the National Cardiovascular Data Registry's Acute Coronary Treatment and Intervention Outcomes Network-Get With The Guidelines Registry from January 2007 to June 2010. Patients who were not seen initially in the ED, were transferred in, or were missing time data were excluded. We analyzed the association between ED administration of thienopyridines and outcomes and patient demographics.
Results:
Of the cohort receiving a thienopyridine within 24 hours, 9534 (24.2%) received it in the ED. Emergency department administration of a thienopyridine was not associated with in-hospital major bleeding (multivariable adjusted odds ratio, 0.99; 95% confidence interval, 0.91-1.09) or in-hospital mortality (adjusted 1.02; 95% confidence interval, 0.86-1.20). Independent predictors most strongly associated with ED thienopyridine administration were elevated troponin, ED length of stay, prior percutaneous coronary intervention, and initial electrocardiogram showing ischemic changes.
Conclusions:
There was no association between ED thienopyridine administration and in-hospital major bleeding or mortality. Emergency department length of stay, electrocardiographic changes, and elevated troponin were associated with ED thienopyridine administration.
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