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Brilliant Board Review & CME
🎙️ Brilliant Medicine: Your Internal Medicine Edge
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Brilliant Board Review & CME
🎙️ 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.
All right, let's talk about P2Y12 inhibitors, pretreatment and NSTEMIs. Now, this was a large observational study, over 100,000. 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. 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:Now, preloading or pre-treating was not associated with reduced ischemic events or increased bleeding events. So the hospital 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: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, 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: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. 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.