TOPLINE

In UK clinical practice, a change in policy from routine pretreatment to no routine pretreatment with a P2Y12 inhibitor was associated with higher odds of in-hospital ST-elevation myocardial infarction (STEMI) but lower odds of actionable bleeding events in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS).

METHODOLOGY

• Researchers conducted a retrospective study to assess whether changing the clinical policy from a routine dual antiplatelet therapy pretreatment strategy to a no routine pretreatment strategy affected in-hospital ischaemic and bleeding outcomes among patients with NSTE-ACS.
• They included 2506 consecutive patients (mean age, 64.8 years; 69.7% men) with NSTE-ACS who were referred for coronary angiography at a tertiary cardiac centre in England between January 2021 and June 2023.
• Patients were divided into two cohorts: a routine pretreatment cohort (n = 1219), in which a P2Y12 inhibitor was given in addition to aspirin before coronary angiography, and a no routine pretreatment cohort (n = 1287), in which patients typically received aspirin alone before angiography and a P2Y12 inhibitor in the catheter laboratory unless they were referred for coronary artery bypass graft surgery.
• The primary outcome was the incidence of in-hospital STEMI; safety endpoints were actionable bleeding events before discharge.
• The median waiting time from admission to coronary angiography was 3.6 days.

TAKEAWAY

• A no routine pretreatment strategy was associated with more than fourfold higher odds of in-hospital STEMI than a routine pretreatment strategy (adjusted odds ratio, 4.40; P < .05).
• Patients in the no routine pretreatment group had 82% lower odds of actionable bleeding events than those in the routine pretreatment group (P < .05).
• Similarly, patients in the no routine pretreatment group had 57% lower odds of non-actionable bleeding events than those in the routine pretreatment group (P < .001).
• In the no routine pretreatment group, the risk for in-hospital STEMI increased by 13% with each additional day of waiting for coronary angiography (P for interaction = .026).

IN PRACTICE

"Waiting times in the UK for in-patient coronary angiography are typically much longer than the trials on which guidance is based, which may impact the risk/benefit balance in clinical practice. Clinical trial evidence and guideline recommendations must be interpreted within a local healthcare context," the researchers wrote.

SOURCE

The study was led by Kerrick Hesse, South Tees Hospitals NHS Foundation Trust, Middlesbrough, and Jessica Stephens, York Hospitals NHS Foundation Trust, York, both in England. It was published online on September 12, 2026, in Open Heart.

LIMITATIONS

The retrospective observational design was subject to the inherent limitations. Patients were analysed according to the treatment policy at presentation rather than the therapy actually received. The study did not include patients managed conservatively without an invasive strategy, which may have limited the applicability of the findings to all patients with NSTE-ACS.

DISCLOSURES

One author received support through a British Heart Foundation Clinical Research Training Fellowship, and another received support through a British Heart Foundation Consultant Research Award. One author disclosed receiving grant funding through an academic institution from industry sources.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.