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Precatheterization Use of P2Y12 Inhibitors in Non-ST-Elevation Myocardial Infarction Patients Undergoing Early
Marwan Badri1,2, Amr Abdelbaky3, Shuang Li4
1Lankenau Medical Center and Institute for Medical Research, Wynnewood, PA marwanbadri@gmail.com.
Insights
Precatheterization P2Y12 inhibitor use in non-ST-elevation myocardial infarction patients undergoing coronary artery bypass grafting is common. This practice is linked to increased delays in surgery and higher risks of post-operative bleeding and transfusion.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiovascular Surgery
Background:
- Current guidelines advocate early P2Y12 inhibitor administration for non-ST-elevation myocardial infarction (NSTEMI).
- The impact of precatheterization P2Y12 inhibitor use on delays to coronary artery bypass grafting (CABG) and postoperative outcomes remains unclear.
- This study investigates the patterns and consequences of P2Y12 inhibitor administration before catheterization in NSTEMI patients who subsequently undergo CABG.
Purpose of the Study:
- To examine the association between precatheterization P2Y12 inhibitor use and time to CABG in NSTEMI patients.
- To assess the relationship between precatheterization P2Y12 inhibitor use and the risk of major bleeding and transfusion after CABG.
- To compare outcomes among NSTEMI patients receiving different P2Y12 inhibitors before catheterization and CABG.
Main Methods:
- Retrospective analysis of 20,304 NSTEMI patients from the ACTION Registry (2009-2014).
- Inclusion criteria: catheterization within 24 hours of admission and CABG during the index hospitalization.
- Inverse probability-weighted propensity score adjustment was used to compare outcomes between patients who received precatheterization P2Y12 inhibitors and those who did not.
Main Results:
- 32.9% of NSTEMI patients received a precatheterization P2Y12 inhibitor (ticagrelor 2.2%, prasugrel 3.7%).
- Precatheterization P2Y12 inhibitor use was associated with longer time from catheterization to CABG (median 69.9 vs. 43.5 hours, P<0.0001).
- Higher risks of post-CABG major bleeding (adjusted OR 1.33) and transfusion (adjusted OR 1.51) were observed in pretreated patients, irrespective of the specific P2Y12 inhibitor used.
Conclusions:
- Precatheterization P2Y12 inhibitor use is prevalent in NSTEMI patients undergoing early catheterization and in-hospital CABG.
- Despite increased delays, most pretreated patients undergo CABG within 3 days post-catheterization.
- Precatheterization P2Y12 inhibitor administration is associated with increased risks of postoperative bleeding and transfusion in NSTEMI patients undergoing CABG.
Background:
Current guidelines recommend early P2Y12 inhibitor administration in non-ST-elevation myocardial infarction, but it is unclear if precatheterization use is associated with longer delays to coronary artery bypass grafting (CABG) or higher risk of post-CABG bleeding and transfusion. This study examines the patterns and outcomes of precatheterization P2Y12 inhibitor use in non-ST-elevation myocardial infarction patients who undergo CABG.
Methods And Results:
Retrospective analysis was done of 20 304 non-ST-elevation myocardial infarction patients in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry (2009-2014) who underwent catheterization within 24 hours of admission and CABG during the index hospitalization. Using inverse probability-weighted propensity adjustment, we compared time from catheterization to CABG, post-CABG bleeding, and transfusion rates between patients who did and did not receive precatheterization P2Y12 inhibitors. Among study patients, 32.9% received a precatheterization P2Y12 inhibitor (of these, 2.2% were given ticagrelor and 3.7% prasugrel). Time from catheterization to CABG was longer among patients who received precatheterization P2Y12 inhibitor (median 69.9 hours [25th, 75th percentiles 28.2, 115.8] versus 43.5 hours [21.0, 71.8], P<0.0001), longer for patients treated with prasugrel (median 114.4 hours [66.5, 155.5]) or ticagrelor (90.4 hours [48.7, 124.5]) compared with clopidogrel (69.3 [27.5, 114.6], P<0.0001). Precatheterization P2Y12 inhibitor use was associated with a higher risk of post-CABG major bleeding (75.7% versus 73.4%, adjusted odds ratio 1.33, 95% confidence interval 1.22-1.45, P<0.0001) and transfusion (47.6% versus 35.7%, adjusted odds ratio 1.51, 95% confidence interval 1.41-1.62, P<0001); these relationships did not differ among patients treated with clopidogrel, prasugrel, or ticagrelor.
Conclusions:
Precatheterization P2Y12 inhibitor use occurs commonly among non-ST-elevation myocardial infarction patients who undergo early catheterization and in-hospital CABG. Despite longer delays to surgery, the majority of pretreated patients proceed to CABG <3 days postcatheterization. Precatheterization P2Y12 inhibitor use is associated with higher risks of postoperative bleeding and transfusion.
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