Precatheterization Use of P2Y ₁₂ 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 ^®

Abstract

BackgroundCurrent 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 ResultsRetrospective 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.ConclusionsPrecatheterization 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.

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

“…Due to increased platelet action, it is a common practice advocated by guidelines [ 18 ] to pretreat MI patients with antiplatelet adenosine diphosphate P2Y12 receptor antagonist (clopidogrel, prasugrel or ticagrelor) before coronary angiography. However, in recent findings, the increased re-sternotomy and bleeding rates [ 19 ] in MI patients undergoing CABG and non-effectiveness of pre-treatment prior to PCI [ 20 ], question the benefits of routine P2Y12 inhibitor preloading in NSTEMI patients, especially if left main or multivessel disease is suspected.…”

Oral Antiplatelet Therapy Administered Upstream to Patients With NSTEMI

“… 30 In upstream-loaded patients, the interval from DA to surgery was only 3–4 days. Contemporary data from the National Cardiovascular Data Registry indicate that the median time from DA to CABG among patients with NSTEMI who are not treated with upstream P2Y 12 i is 43.5 hours, 31 and so the incremental difference may not be as striking as it first appears, particularly since in PLATO, guidance for CABG in ticagrelor-loaded patients was to wait only 24–72 hours. 2 …”

Assessment of Pretreatment With Oral P2Y12 Inhibitors and Cardiovascular and Bleeding Outcomes in Patients With Non-ST Elevation Acute Coronary Syndromes

“…Conversely, the ACCOAST trial demonstrated no interaction between access site and the observed increase in bleeding risk. 28 Nevertheless, decisions regarding access site may not be known at the time of pretreatment; multiple recent observational studies have demonstrated pretreatment is associated with increased bleeding risk among patients who require bypass surgery or among those with an alternate diagnosis (eg, aortic dissection) [29][30][31] ; and most importantly, no benefit in regards to ischemic end points was observed.…”