Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain.
Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain.
J Am Coll Cardiol. 2024 Jun 25;83(25):2629-2639. doi: 10.1016/j.jacc.2024.04.036.
The optimal timing of P2Y inhibitor administration in patients with ST-segment elevation myocardial infarction (STEMI) has not been completely elucidating.
This analysis from a prospective multicenter registry sought to assess the safety and effectiveness of P2Y inhibitor pretreatment in patients transferred for primary percutaneous coronary intervention (PCI) within a regional STEMI network.
Pretreatment was defined as P2Y inhibitor administration before coronary angiography. Endpoints were major adverse cardiac events (MACE), major bleeding, and net adverse clinical events, a composite of MACE or major bleeding, within 30 days of index admission. Association of P2Y inhibitor pretreatment with outcomes was modeled using doubly robust weighted estimators based on propensity score analysis.
Of 1,624 patients included, 1,033 received P2Y inhibitors before angiography and 591 in the catheterization laboratory (cath lab). The non-pretreated cohort more often had history of coronary artery disease and were more likely to receive antiplatelet therapy before the index admission. After adjustment for confounding and dependent censoring, pretreatment with P2Y inhibitors predicted lower risk of MACE (adjusted HR: 0.53; 95% CI: 0.37-0.76), without increasing bleeding risk (adjusted HR: 0.62; 95% CI: 0.36-1.05), resulting in superior net clinical benefit (adjusted HR: 0.47; 95% CI: 0.26-0.86) compared with in-cath lab administration of P2Y inhibitors. There was a significant treatment-by-time interaction for MACE risk, whereby the observed benefits of pretreatment only became apparent when time between P2Y inhibitor administration and PCI was longer than 80 minutes.
In contemporary patients with STEMI transferred for primary PCI, pretreatment with P2Y inhibitors was associated with a significant time-dependent reduction of 30-day MACE without increasing bleeding risk.
ST 段抬高型心肌梗死（STEMI）患者中 P2Y 抑制剂给药的最佳时机尚未完全阐明。
本分析来自一个前瞻性多中心注册研究，旨在评估在区域 STEMI 网络内接受直接经皮冠状动脉介入治疗（PCI）的患者中 P2Y 抑制剂预处理的安全性和有效性。
预处理定义为冠状动脉造影前给予 P2Y 抑制剂。终点是 30 天内的主要不良心脏事件（MACE）、大出血和净不良临床事件（MACE 或大出血的复合）。使用基于倾向评分分析的双重稳健加权估计器对 P2Y 抑制剂预处理与结局的关系进行建模。
在纳入的 1624 例患者中，1033 例在血管造影前接受了 P2Y 抑制剂治疗，591 例在导管室（cath lab）接受了 P2Y 抑制剂治疗。未预处理组更常患有冠状动脉疾病，且更有可能在指数入院前接受抗血小板治疗。在调整混杂因素和依赖 censoring 后，P2Y 抑制剂预处理预测 MACE 风险降低（校正 HR：0.53；95%CI：0.37-0.76），而不增加出血风险（校正 HR：0.62；95%CI：0.36-1.05），与导管室给予 P2Y 抑制剂相比，具有更好的净临床获益（校正 HR：0.47；95%CI：0.26-0.86）。MACE 风险存在显著的治疗-时间交互作用，即只有当 P2Y 抑制剂给药和 PCI 之间的时间超过 80 分钟时，预处理的观察到的益处才会显现。
在接受直接 PCI 的当代 STEMI 患者中，P2Y 抑制剂预处理与 30 天 MACE 显著降低相关，而不增加出血风险。
