In NSTEMI patients undergoing PCI, P2Y12 pretreatment did not reduce type 4a MI but increased the risk of in-hospital bleeding and net clinical risk (matched OR 1.45; 95% CI 1.06-1.97; p=0.019).
Cohort (n=1,254)
Yes
Does P2Y12 receptor inhibitor pretreatment improve in-hospital net clinical benefit in NSTEMI patients undergoing PCI?
P2Y12 pretreatment in NSTEMI patients undergoing PCI increases in-hospital bleeding without reducing type 4a MI, supporting current guidelines against routine pretreatment.
Odds Ratio: 1.45 (95% CI 1.06–1.97)
p-value: p=0.019
Abstract Introduction Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the standard treatment for patients with non-ST-elevation myocardial infarction (NSTEMI). While pretreatment with P2Y12 inhibitors has been widely used in acute coronary syndromes, the 2020 ESC guidelines advise against routine pretreatment in NSTEMI patients undergoing early percutaneous coronary intervention (PCI) (within 24 hours) until coronary anatomy is confirmed. However, the effect of pretreatment on type 4a myocardial infarction (MI) in this context remains uncertain. Methods We analyzed consecutive NSTEMI patients who underwent PCI between January 2017 and April 2023 using the multicenter AMIPE registry. Patients were divided into two cohorts based on institutional protocols: Cohort 1 (January 2017–August 2020) received P2Y12 treatment before coronary angiography, while Cohort 2 (September 2020–April 2023) received P2Y12 treatment only after coronary anatomy was confirmed. Eligible patients had stable or decreasing cTn levels to ensure an accurate diagnosis of type 4a MI, while those with pre-PCI unstable cTn levels (variation 20%), guideline non-adherence, age 18 years, or lack of informed consent were excluded. The primary endpoint was in-hospital net clinical benefit, defined as type 4a MI and Bleeding Academic Research Consortium (BARC) Scale type 2, 3, or 5 bleeding. Secondary endpoints included 30-day major adverse cardiovascular events (MACE: all-cause mortality, reinfarction, ischemic stroke, or heart failure hospitalization) and net adverse clinical events (NACE: MACE, type 4a MI, and in-hospital BARC type 2, 3, or 5 bleeding). Propensity score matching was used to balance baseline characteristics between groups. Univariable logistic regression calculated ORs (95% CIs) for the primary endpoint and its components. Kaplan-Meier curves and the log-rank test assessed 30-day NACE survival. Results After applying predefined exclusion criteria, 1,254 NSTEMI patients were included and divided into two cohorts: those who received P2Y12 pretreatment before September 2020 (Cohort 1) and those treated at the time of PCI after September 2020 (Cohort 2). Propensity score matching yielded 502 well-balanced pairs. Pretreatment did not reduce the incidence of type 4a MI but was associated with a higher risk of in-hospital bleeding. Logistic regression confirmed an increased net clinical risk in both the unmatched and matched populations, driven by in-hospital bleeding (unmatched: OR 1.34, 95% CI 1.01–1.79, p=0.042; matched: OR 1.45, 95% CI 1.06–1.97, p=0.019). 30-day MACE rates were similar between cohorts, while Kaplan-Meier curves showed worse 30-day NACE survival in Cohort 1 (p=0.041 unmatched; p=0.013 matched), driven primarily by in-hospital bleeding. Conclusion In NSTEMI patients undergoing PCI, P2Y12 pretreatment does not reduce type 4a MI but increases in-hospital bleeding, leading to a higher net clinical risk.
Vasumini et al. (2025) conducted a cohort in Non-ST-segment elevation myocardial infarction (NSTEMI) (n=1,254). P2Y12 receptor inhibitor pretreatment vs. P2Y12 treatment only after coronary anatomy was confirmed (at the time of PCI) was evaluated on In-hospital net clinical benefit, defined as type 4a MI and Bleeding Academic Research Consortium (BARC) Scale type 2, 3, or 5 bleeding (OR 1.45, 95% CI 1.06-1.97, p=0.019). In NSTEMI patients undergoing PCI, P2Y12 pretreatment did not reduce type 4a MI but increased the risk of in-hospital bleeding and net clinical risk (matched OR 1.45; 95% CI 1.06-1.97; p=0.019).