Background

Although high rates of P2Y₁₂ inhibitor pretreatment (defined as the administration before coronary angiography) for non–ST-segment elevation acute coronary syndrome (NSTE-ACS) have been reported, contemporary U.S. practice patterns are not well studied.

Objectives

The goal of this study was to investigate the temporal U.S. trends, variability, and clinical outcomes of P2Y₁₂ inhibitor pretreatment in NSTE-ACS.

Methods

Consecutive patients who underwent early invasive strategy for NSTE-ACS (coronary angiography ≤24 hours of arrival) in the National Cardiovascular Data Registry 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 2013Q1 to 12.4% in 2023Q1. 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 2 similar patients would have a >3-fold difference in the odds of pretreatment from 1 random operator or institution as compared with another (median OR: 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, 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, we 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, our findings highlight the importance of efforts to improve standardization.

中文翻译：

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非 ST 段抬高型急性冠脉综合征的 P2Y12 抑制剂预处理：NCDR 胸痛-MI 登记处

 背景

尽管已报道非 ST 段抬高型急性冠脉综合征 （NSTE-ACS） 的 P2Y₁₂ 抑制剂预处理率（定义为冠状动脉造影前给药）的高发生率，但当代美国的实践模式尚未得到很好的研究。

 目标

本研究的目的是调查 NSTE-ACS 中 P2Y₁₂ 抑制剂预处理的时间美国趋势、变异性和临床结果。

 方法

分析了在美国心血管数据登记处胸痛-心肌梗死 （MI） 登记处接受 NSTE-ACS 早期侵入性策略 （冠状动脉造影 ≤到达后 24 小时） 的连续患者。在 2013 年 1 月 1 日至 2023 年 3 月 31 日期间对一个完整的队列进行了时间趋势分析。随后，使用具有完整变量集的较新的队列（2019 年 1 月 1 日至 2023 年 3 月 31 日）来构建分层回归模型，以量化运营商和机构之间使用预处理的可变性。对于这个当代队列，以操作员偏好为工具，进行工具变量分析，以比较接受预处理的患者和未接受预处理的患者之间的院内结果。

 结果

P2Y₁₂ 抑制剂预处理的使用从 2013 年第一季度的 24.8% 下降到 2023 年第一季度的 12.4%。在当代 110,148 名患者队列中 （2019-2023;平均年龄 63.9 ± 12.5 岁;33.0% 为女性），17,509 名 （15.9%） 接受了预处理。观察到 P2Y₁₂ 抑制剂预处理的显著变异性 （范围：0%-100%）：分层回归模型表明，与另一个随机运营商或机构相比，1 个随机运营商或机构的 2 名相似患者的治疗几率差异为 >3 倍（中位 OR：分别为 3.74 [95% CI：3.57-3.91] 和 3.63 [95% CI：3.51-3.74]）。工具变量分析显示，院内全因死亡无显著差异 （1.5% 对 1.7%;P = 0.07）、复发性 MI （0.6% 对 0.6%;P = 0.98）或大出血 （2.7% vs 2.8%;P = 0.98）。然而，在接受冠状动脉搭桥手术的患者中，预处理与更长的住院时间相关（11.2 ± 5.1 天 vs 9.8 ± 5.0 天;P < 0.01）。

 结论

在美国国家登记处，我们观察到 NSTE-ACS 患者 P2Y₁₂ 抑制剂预处理的使用存在显著差异。鉴于缺乏明显的优势和延长住院时间的可能性，我们的研究结果强调了努力提高标准化的重要性。