The efficacy of early versus delayed P2Y12 inhibition in percutaneous coronary intervention for ST-elevation myocardial infarction: a systematic review and meta-analysis

Bellemain-Appaix, Anne; Bégué, Céline; Bhatt, Deepak L.; Ducci, Kenneth; Harrington, Robert A.; Roe, Matthew T.; Wiviott, Stephen D.; Cucherat, Michel; Silvain, Jean‐François; Collet, Jean‐Philippe; Bertucci, François; Montalescot, Gilles

doi:10.4244/eij-d-17-00852

Cited by 31 publications

(17 citation statements)

References 27 publications

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“… 2 Most of the available data in favor of pretreatment with P2Y12 receptor antagonists in NSTE-ACS are indirect and old. 3 , 4 , 5 , 6 , 7 , 8 , 9 To our knowledge, no previous trials of the timing of treatment with P2Y12 receptor antagonists have had the adequate statistical power to evaluate mortality and clinically relevant complications. The only randomized clinical trial to our knowledge in patients with NSTE-ACS not only found that pretreatment with a P2Y12 receptor antagonist (ie, prasugrel) was not beneficial but also that pretreatment was harmful, owing to increased risk of major bleeding.…”

Section: Introductionmentioning

confidence: 99%

Association of Pretreatment With P2Y12 Receptor Antagonists Preceding Percutaneous Coronary Intervention in Non–ST-Segment Elevation Acute Coronary Syndromes With Outcomes

et al. 2020

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Key Points Question Is a pretreatment strategy with P2Y12 receptor antagonists associated with better outcomes vs no pretreatment in patients with non–ST-segment elevation acute coronary syndrome undergoing percutaneous coronary intervention? Findings This cohort study including 64 857 patients from the Swedish Coronary Angiography and Angioplasty Registry found that pretreatment with P2Y12 receptor antagonists was not associated with improved survival nor a lower risk of stent thrombosis but was associated with increased risk of bleeding. Meaning These findings suggest that pretreatment with P2Y12 receptor antagonists should not be routinely used in non–ST-segment elevation acute coronary syndrome.

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Section: Introductionmentioning

confidence: 99%

Association of Pretreatment With P2Y12 Receptor Antagonists Preceding Percutaneous Coronary Intervention in Non–ST-Segment Elevation Acute Coronary Syndromes With Outcomes

et al. 2020

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“…Furthermore, in vitro models have shown that P2Y 12 agents can disrupt and even reverse thrombus stability [15,16]. Longer pretreatment with P2Y12 agents is also associated with improved coronary perfusion before PCI [17]. In this study, the proportion of patients with coronary thrombus was significantly higher in the early intervention group.…”

Section: Benefits Of Early Versus Delayed Angiographymentioning

confidence: 51%

464Optimal timing of invasive coronary angiography following NSTEMI

Mahendiran

Nanchen

Meier

et al. 2019

European Heart Journal

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Introduction Current guidelines recommend angiography within 24 hours of hospitalisation for patients with non-ST elevation myocardial infarction (NSTEMI). The recent VERDICT study found that angiography within 12 hours of hospitalisation was associated with improved cardiovascular outcomes among high-risk patients. We aimed to obtain a real-world perspective of the impact of angiography timing on one-year outcomes of patients admitted with NSTEMI. Methods Data was obtained from the SPUM-ACS registry, a cohort of consecutive patients hospitalised with acute coronary syndromes in four university hospitals in Switzerland between 2009 and 2017. Patients without a door-to-catheter (DTC) time and those with life-threatening features were excluded. Cox proportional hazards models evaluated the impact of DTC time on the primary endpoint, defined as one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, stroke), and on one-year all-cause mortality. Results Of 2,672 NSTEMI patients, 1,832 met the inclusion criteria. Among them, 1,464 patients underwent angiography within 12 hours of admission (12h group) while 368 patients underwent angiography between 12 and 24 hours (12–24h group). After 2:1 propensity score matching, 736 patients from the 12h group and 368 patients from the 12–24h group were deemed equivalent in terms of main baseline clinical characteristics. Multiple logistic regression identified admission out-of-hours (night or weekend) as the most significant factor associated with delayed angiography. Cox models found no significant association between early angiography and one-year MACE (12h group: n=57 (7.7%) vs. 12–24h group: n=27 (7.3%), HR: 1.050, 95% CI 0.637- 1.733, p=0.847), or one-year all-cause mortality (12h group: n=25 (3.4%) vs. 12–24h group: n=17 (4.6%), HR: 1.514, 95% CI 0.774- 2.962, p=0.225) (Figure 1A). After stratification based on GRACE score (>140 vs. ≤140), there was no significant difference in one-year MACE or one-year all-cause mortality in the 12h group compared with the 12–24h group (p for interaction=0.601 and 0.463, respectively) (Figure 1A + 1B). Figure 1 Conclusion In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of hospitalisation was not associated with improved one-year outcomes when compared with angiography between 12 and 24 hours, even among patients with an elevated GRACE score.

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“…However, a recent meta-analysis of clinical studies has clearly shown that an early effective P2Y 12 inhibition is desirable, as it significantly reduces ischemic events, without an increase in major bleedings. 52 A similar concept is supported by a clinical outcome study of the intravenously administered P2Y 12 receptor inhibitors cangrelor, as tested over clopidogrel. 53 In the very recently published CANTIC (Platelet Inhibition With CANgrelor and Crushed TICagrelor in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention) study, cangrelor was compared with placebo in 50 patients all of whom had been loaded with crushed ticagrelor 180 mg LD.…”

Section: Crushed P2y 12 Receptor Inhibitors Tablets In Out-of-hospitamentioning

confidence: 90%

Loading with Oral P2Y12 Receptor Inhibitors: To Crush or Not to Crush?

2019

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Oral P2Y12 receptor inhibitors represent a mainstay treatment in patients with acute coronary syndrome and those undergoing percutaneous coronary intervention. In the setting of ST-elevation myocardial infarction, when early platelet inhibition is highly desirable, the onset of action of oral P2Y12 receptor inhibitors is, however, delayed, likely due to delayed drug absorption. Crushing the tablets, which are to be used for patient loading with an oral P2Y12 receptor inhibitor, has been shown to provide earlier platelet inhibition than standard, integral tablets administration. Chewed ticagrelor tablets may also result in a similar effect. Such findings should be interpreted with caution, mainly due to the small number of patients enrolled and the nature (pharmacodynamic/pharmacokinetic) of the respective studies. Furthermore, in patients with out-of-hospital cardiac arrest, who remain comatose, crushing tablets is commonly applied in clinical practice for platelet P2Y12 receptor inhibition. In this review, we focus on current evidence regarding the role of crushed P2Y12 receptor inhibitor pills, analyzing clinical scenarios where most of the promise exists along with future expectations from this type of formulation. Large randomized studies are needed to draw firm conclusions regarding the clinical benefit of ‘crushing’ over the usual ‘not-crushing’ practice.

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The efficacy of early versus delayed P2Y12 inhibition in percutaneous coronary intervention for ST-elevation myocardial infarction: a systematic review and meta-analysis

Abstract: A strategy of early effective P2Y12 inhibition in PCI of STEMI appears to improve coronary reperfusion before PCI, and reduce MACE, MI and bail-out GPI use without increase of major bleeding.

Cited by 31 publications

References 27 publications

Association of Pretreatment With P2Y12 Receptor Antagonists Preceding Percutaneous Coronary Intervention in Non–ST-Segment Elevation Acute Coronary Syndromes With Outcomes

Association of Pretreatment With P2Y12 Receptor Antagonists Preceding Percutaneous Coronary Intervention in Non–ST-Segment Elevation Acute Coronary Syndromes With Outcomes

464Optimal timing of invasive coronary angiography following NSTEMI

Loading with Oral P2Y12 Receptor Inhibitors: To Crush or Not to Crush?

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