Original title: Reappraisal of thienopyridine pretreatment in patients with non-ST elevation acute coronary syndrome: a systematic review and meta-analysis. Reference: Bellemain-Appaix A. et al. BMJ. 2014;Epub ahead of print.
This meta-analysis included 7 studies that included a total 32383 patients admitted with non ST elevation ACS; 17545 (54.5%) underwent PCI. These studies were published between 2001 and 2013: 3 were randomized, 1 was a sub study of a randomized study and 3 were observational studies.
Thienopyridine pretreatment varied in the different studies. For most patients it consisted of a 300 mg clopidogrel loading dose, one used a 600 mg and another was left to operator’s criteria. In the ACCOAST study, patients randomized to pretreatment received 30mg of prasugrel at admission and when PCI was required, the loading dose was completed with 30 additional mg.
Pretreatment was no associated with a lower risk of all cause or cardiovascular death in the whole cohort or in PCI patients, though a significant increase of bleeding was observed.
When looking at randomized studies alone, efficacy was similar but bleeding was similar. In the complete cohort, pretreatment did reduce the secondary end point, a combination of MACE (OR 0.84; IC 95% 0.72 to 0.98); however, when considering only AMI, the difference was not significant (OR 0.81; IC 95% 0.64 to 1.03). Stroke and urgent revascularization were similar despite pretreatment.
In the PCI cohort, pretreatment only reduced urgent revascularization and this benefit was seen in the subgroup of patients from CURE that underwent PCI.
Conclusion
Thyenopiridine pretreatment in non-ST elevation ACS patients does not reduce mortality and causes excess bleeding.
Editorial Comment
The concept of systematic and immediate pretreatment with a P2Y12 receptor antagonist in non-ST elevation ACS patients needs further consideration, especially in the light of the fact that the sub study of CURE PCI patients was carried out more than 10 years ago and that it was not designed to evaluate pretreatment efficacy. In addition, new, more effective P2Y12 receptor inhibitors have come out in recent years.
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