Pretreatment with DAPT in Acute Coronary Syndrome: An Ongoing Debate?

In acute coronary syndrome (ACS) dual antiplatelet therapy (DAPT) has become a fundamental pillar after percutaneous coronary intervention (PCI), preventing stent thrombosis and acute myocardial infarction recurrence (AMI). However, the clinical benefit of preloading DAPT, pretreatment with aspirin and P2Y12 receptor inhibitors, remains controversial, and the most recent European guidelines advise against its use in patients with non ST elevation ACS (NST-ACS).

The aim of this study carried out by Goh et al. was to assess the prevalence of preloading DAPT and its clinical outcomes in a contemporary cohort of patients in Victoria, Australia, included in the Victorian Cardiac Outcomes Registry (VCOR) between 2014 and 2021.

42,453 PCI procedures done for ACS were looked at; 79% of these patients received DAPT prior intervention (n=33,520). Pretreated patients were generally younger and presented fewer comorbidities, such as peripheral vascular disease, cerebrovascular disease, kidney failure and a store of revascularization surgery. The most used antiaggregant was ticagrelor, vs thienopyridine inhibitors (59.5% vs. 23.4%).

At raw analysis, the pretreated group presented lower inhospital mortality (2.6% vs. 5.6%; p<0.001) and at 30 days (3.3% vs. 6.4%; p<0.001), as well as lower major cardiovascular events incidence (MACE) at 30 days (5.5% vs. 8.8%; p<0.001) and lower major bleeding rate (1.0% vs. 1.7%; p<0.001). However, after adjusting form variables with multivariable analysis, no significant differences were found in total mortality, MACE or stent thrombosis. 

DAPT preloading was independently associated with reduced incidence of major bleeding at 30 days (OR 0.79; CI95%: 0.65–0.96; p=0.02), particularly in the NST-ACS subgroup. An exploratory analysis showed the use of thienopyridines might be associated with lower MACE rate vs ticagrelor (OR 0.81; CI95%: 0.70–0.94; p=0.006).

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When stratifying by presentation type (SCASEST vs. SCACEST), no significant differences were found as regards mortality or MACE.

Conclusions

In this contemporary cohort of ACS patients in Australia, DAPT preloading was common practice, though it was not independently associated with reduced mortality, MACE or stent thrombosis. 

Original Title: Dual Antiplatelet Therapy Prior to Percutaneous Coronary Intervention for Acute Coronary Syndrome: Prevalence and Outcomes in Contemporary Practice.

Reference: Goh SH, Batchelor R, Dinh D, Brennan A, Peters S, Stub D, Reid C, Chan W, Liew D, Wilson W, Lefkovits J; VCOR investigators. Dual Antiplatelet Therapy Prior to Percutaneous Coronary Intervention for Acute Coronary Syndrome: Prevalence and Outcomes in Contemporary Practice. Catheter Cardiovasc Interv. 2025 Apr 8. doi: 10.1002/ccd.31520. Epub ahead of print. PMID: 40195707.