英国NSTE-ACS患者P2Y12抑制剂预处理策略改变对院内结局的影响
本研究为英国东北部三级心脏中心的回顾性观察研究，纳入2506例计划有创策略的NSTE-ACS住院患者，比较常规P2Y12抑制剂预处理（2021年）与无常规预处理（2022–2023年）两个时期。结果显示无常规预处理策略院内STEMI风险更高，但可行动出血事件风险更低。
要点
- 无常规预处理策略院内STEMI风险显著高于常规预处理策略。
- 无常规预处理策略可行动出血事件风险显著低于常规预处理策略。
- 预处理效应随有创操作等待时间而变化，英国等待时间常长于指南依据的试验。
核心结论
- 从常规P2Y12抑制剂预处理改为无常规预处理策略后，院内STEMI风险更高但出血事件更低。
研究设计与样本
- 回顾性观察研究，纳入英国东北部三级心脏中心2506例计划有创策略的NSTE-ACS住院患者。
- 常规预处理队列为2021年1月1日至12月31日共1219例，无常规预处理队列为2022年7月1日至2023年6月30日共1287例。
- 主要终点为院内STEMI和可行动出血事件，以倾向评分调整后的OR及95%CI报告。
主要发现
- 无常规预处理策略的依从率为84.2%。
- 入院至冠状动脉造影的中位时间为3.6天（IQR 1.9，5.8）。
- 无常规预处理组院内STEMI发生率为1.7%，常规预处理组为0.4%，调整后OR 4.40（95% CI 1.78至13.3）。
- 无常规预处理组可行动出血事件发生率为0.2%，常规预处理组为0.9%，调整后OR 0.18（95% CI 0.03至0.70）。
- 预处理效应受有创操作等待时间影响，与院内STEMI发生率存在交互作用（交互P=0.026）。
关键数值与推荐
- 无常规预处理策略院内STEMI发生率1.7%对比常规预处理策略0.4%，调整后OR 4.40（95% CI 1.78至13.3）。
- 无常规预处理策略可行动出血事件发生率0.2%对比常规预处理策略0.9%，调整后OR 0.18（95% CI 0.03至0.70）。
- 入院至冠状动脉造影中位等待时间为3.6天（IQR 1.9，5.8），长于指南依据试验中的等待时间。
临床怎么用
- 在英国住院患者等待冠状动脉造影时间较长的背景下，常规预处理与无常规预处理策略的获益风险平衡需个体化评估。
局限性
- 回顾性观察设计，可能存在未测量的混杂因素。
- 单中心研究，结果的外推性受限。
- 策略依从率为84.2%，存在交叉 contamination 可能。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
Background Dual antiplatelet therapy is indicated in the management of non-ST-elevation acute coronary syndrome (NSTE-ACS) and can be administered before coronary angiography (pre-treatment) or after coronary anatomy is known. Based on clinical trials with rapid access to inpatient coronary angiography, clinical guidelines recommend invasive assessment prior to commencing a second antiplatelet. We aimed to evaluate the impact of a change in clinical policy from routine P2Y 12 inhibitor pre-treatment to no routine pre-treatment on in-hospital outcomes in a UK healthcare context. Methods A retrospective observational study of hospitalised NSTE-ACS patients with a planned invasive strategy at a tertiary cardiac centre in Northeast England was conducted. Two cohorts were identified: routine pre-treatment (1 January 2021 to 31 December 2021) and no routine pre-treatment (1 July 2022 to 30 June 2023). Primary endpoints were in-hospital ST-elevation myocardial infarction (STEMI) and actionable bleeding events, reported as propensity score-adjusted ORs (ORs) and 95% CIs. Results Of 2506 NSTE-ACS cases, 1219 presented before and 1287 after the policy change, which was adhered to in most cases (84.2%). Median time from admission to angiography was 3.6 days (IQR 1.9, 5.8). In comparison to a routine pre-treatment strategy, a no routine pre-treatment strategy was associated with greater risk of in-hospital STEMI (1.7% vs 0.4%, adjusted OR 4.40, 95% CI 1.78 to 13.3), but lower risk of actionable bleeding events (0.2% vs 0.9%, adjusted OR 0.18, 95% CI 0.03 to 0.70). There was evidence of pre-treatment effect modification by procedural waiting time on in-hospital STEMI incidence (p for interaction=0.026). Conclusion We observed a greater risk of in-hospital STEMI but lower rates of bleeding following the change from a routine pre-treatment to a no routine pre-treatment strategy. UK waiting times for in-patient coronary angiography are typically considerably longer than the trials on which guidance is based, which may impact the risk/benefit balance in clinical practice.
引用
- Open Heart：P2Y12 inhibitor pre-treatment in NSTE-ACS: translating trial evidence into UK clinical practice
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。