🎙️ Episode 24: Pretreat or Nah? P2Y12s in NSTEMI Under Fire

🧠 Historical practice:

Pre-load clopidogrel (or ticagrelor) before cath.

Rationale: reduce thrombotic burden prior to PCI.

🧪 New Data:

Large observational study: 100k+ NSTEMI patients.

No benefit in MI or death with pretreatment.

Longer LOS, delayed CABG in pre-treated patients.

🧩 Clinical Takeaway:

Defer P2Y12 until coronary anatomy is known — especially if CABG is on the table.

If PCI is clearly planned and delay expected — preloading may still be reasonable.

Transcript

Speaker 1 0:02

All right , let's talk about P2Y12 inhibitors , pretreatment and NSTEMIs . Now , this was a large observational study , over 100,000 .

P2Y12 Inhibitors and NSTEMI Study

Speaker 1 0:12

They went through and reviewed the data and these are the ones of the clopidogrel , plasigrel and ticagrelor and this is going to depend on your facility Used to be in the past , you'd load them In clopidogrel , you'd load them about 600 milligrams and then they would go through their treatment in the cath lab and then if the patient happened to need a cabbage , you'd have to delay and most of the CT surgeons would want to have what they call a Clopidogrel washout period . Now some of the surgeons would do with a Ticagrelor . They would use that one right away and you could experience that differently in your facility .

Challenges With Pre-Loading Patients

Speaker 1 0:51

But the main thing is is we'd load these patients up and then they would go to the cath lab and then you're like , oh crap , now that they received those , we have to watch them . And those are the worst patients to watch because you know that they have disease and they're going to have chest pain , but you got to wait for them to have a surgery and those are not great events to have , especially if you're watching these people on the cardiac wards or even the ICU wards . You're like oh , come on , we got to get them through these seven days most places would want to have .

Speaker 1 1:21

Now , preloading or pre-treating was not associated with reduced ischemic events or increased bleeding events . So the hospital

Study Results on Pre-Treatment

Speaker 1 1:31

death was 1.5 to 1.7 and this was the pre-treatment versus non-pre-treatment . Mi's was the same as 0.6 . In both Major bleed was about the same . The pre-treatment is actually a little bit less 2.7 to 2.8 . The length of stay this is the big deal , this 11.2 days versus 9.8 days , and I actually think , if you really look at it , it'd be longer , because you're holding these people for an extra seven days before you can get them into a CT surgery .

Speaker 1 2:01

If they require CT surgery and this is the big thing is they can delay your cabbage , and that's these people . You want to get them in the cabbage . So what do we do with this ? Is this is a discussion you would have with your cardiology team . So if someone is coming in for an end stemming and say they're going to take them to the cath lab or they're not going to take them to the cath lab ,

Clinical Decision Making Guidelines

Speaker 1 2:23

is you want to discuss do we want to pre-treat or not ? And maybe on the high risk and stemmes we would , and possible those with hemodynamically instability , or once you have to wait for whatever reason . Maybe it's your facility or something's going on where you have to wait until the cath can be done and then .

Speaker 1 2:44

But the better answer would be is if they can get to the cath as soon as possible and then the cardiologist is going to make a decision while they're in the cath going all right , well , we're not going to need to take this patient over for CT surgery , they're not going to need a CABG . So let's give them the treatment right now . We can load them up with Computagrel , plastig grill or ticagalor , depending on your facility . Remember the side effect of ticagalor .

Reducing Hospital Stay Benefits

Speaker 1 3:09

Remember that one Dyspnea , dyspnea , and you can do it afterwards . So that way you're not delaying , you're not keeping people in the hospital longer . Remember , the longer someone stays in the hospital , increased costs . We all know that . But the other thing is increase . Things go wrong when people are in the hospital . We need to get them home . We need to get them to their home environment as soon as possible .