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P2Y12 Inhibitor Pretreatment in NSTE-ACS: NCDR Chest Pain-MI Registry
Quick Takes
- The current analysis from the NCDR Chest Pain-MI Registry evaluated trends in use of P2Y12 inhibitor pretreatment among patients presenting with NSTE-ACS and undergoing coronary angiography from 2013-2023.
- Overall, the use of P2Y12 inhibitor pretreatment declined steadily (50% decline from 2013-2023 and used in a minority of patients from 2019-2023 [15.9%]). There was significant heterogeneity in practice patterns across practice and regional settings.
- Clinical outcomes did not differ based on pretreatment except in patients who underwent CABG (pretreatment was associated with a longer length of stay, 11.2 ± 5.1 days vs. 9.8 ± 5.0 days; p < 0.01).
Study Questions:
What are temporal U.S. trends, variability, and clinical outcomes of P2Y12 inhibitor pretreatment in non–ST-segment elevation acute coronary syndrome (NSTE-ACS)?
Methods:
Consecutive patients who underwent an early invasive strategy for NSTE-ACS (coronary angiography <24 hours of arrival) in the National Cardiovascular Data Registry (NCDR) Chest Pain-Myocardial Infarction (MI) Registry were analyzed. A time-trend analysis was conducted on a complete cohort between January 1, 2013, and March 31, 2023. Subsequently, a more recent cohort (January 1, 2019, to March 31, 2023) with a complete set of variables was used to construct hierarchical regression models to quantify the variability in the use of pretreatment among operators and institutions. For this contemporary cohort, instrumental variable analysis, with operator preference as the instrument, was performed to compare the in-hospital outcomes between patients who received pretreatment and those who did not.
Results:
Use of P2Y12 inhibitor pretreatment decreased from 24.8% in 2013-Q1 to 12.4% in 2023-Q1. Among the contemporary cohort of 110,148 patients (2019-2023; mean age, 63.9 ± 12.5 years; 33.0% female), 17,509 (15.9%) received pretreatment. Significant variability in P2Y12 inhibitor pretreatment was observed (range, 0%-100%): hierarchical regression model demonstrated that two similar patients would have a >3-fold difference in the odds of pretreatment from one random operator or institution as compared with another (median odds ratio, 3.74 [95% CI, 3.57-3.91] and 3.63 [95% CI, 3.51-3.74], respectively). Instrumental variable analysis demonstrated no significant differences in in-hospital all-cause death (1.5% vs. 1.7%; p < 0.07), recurrent MI (0.6% vs. 0.6%; p = 0.98), or major bleeding (2.7% vs. 2.8%; p = 0.98) with pretreatment. However, in patients who underwent coronary artery bypass surgery (CABG), pretreatment was associated with a longer length of stay (11.2 ± 5.1 days vs. 9.8 ± 5.0 days; p < 0.01).
Conclusions:
In a national U.S. registry, the authors observed significant variability in the use of P2Y12 inhibitor pretreatment among NSTE-ACS patients. Given the lack of clear advantages and the potential for prolonged hospital stays, these findings highlight the importance of efforts to improve standardization.
Perspective:
The current analysis from the NCDR Chest Pain-MI Registry evaluated trends in use of P2Y12 inhibitor pretreatment among patients presenting with NSTE-ACS and undergoing coronary angiography from 2013-2023. Overall, the use of P2Y12 inhibitor pretreatment declined steadily (50% decline from 2013-2023 and used in a minority of patients from 2019-2023 [15.9%]). There was significant heterogeneity in practice patterns across practice and regional settings. Clinical outcomes did not differ based on pretreatment except in patients who underwent CABG. Based on prior studies and findings from this analysis, there does not appear to be any benefit of routine pretreatment with a P2Y12 inhibitor in patients with NSTE-ACS.
Clinical Topics: Acute Coronary Syndromes, Cardiovascular Care Team, Stable Ischemic Heart Disease, Vascular Medicine, Chronic Angina
Keywords: Acute Coronary Syndrome, Angina, Unstable, Chest Pain MI Registry, Non-ST Elevated Myocardial Infarction, Receptors, Purinergic P2Y12, AHA Annual Scientific Sessions, AHA24
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