A cohort study demonstrates that the composite of major adverse cardiac or cerebrovascular events (MACCEs) is not improved in patients with ST-segment elevation myocardial infarction (STEMI) who receive P2Y12 inhibitor pretreatment. Miklos Rohla, MD, PhD, of the University of Bern, Switzerland, and colleagues from Switzerland and Japan, reported these data in a manuscript published Monday online and in the Jan. 8 issue of JACC: Cardiovascular Interventions. Many institutions use early P2Y12 inhibitor loading in patients with STEMI despite the lack of research to support this management method. Some studies have shown inconsistent data in the reduction of ischemic outcomes after P2Y12 inhibitor pretreatment. The investigators in this study examined the outcomes of STEMI patients treated with P2Y12 inhibitors at different time periods. Data were collected from the Bern-Percutaneous Coronary Intervention (PCI) registry between 2016 and 2020. Patient cohort 1 (n=1,116; mean age=65.2±12.6 years; 24% female) was recommended for immediate P2Y12 inhibitor treatment, while for patient cohort 2 (n=847; mean age=65.3±12.4 years; 24% female), P2Y12 treatment was recommended post-confirmation of coronary anatomy. Sensitivity analyses were performed on patient data that followed the study recommendations. The primary endpoint of this study was the composite of MACCEs at 30 days. A total of 708 patients in cohort 1 met the study recommendations, as did 798 patients in cohort 2. Baseline characteristics were similar between the cohorts. Between cohorts 1 and 2, 52 minutes was the median difference for loading of P2Y12 to angiography, and 100 minutes between patients who received or did not receive pretreatment. Cohorts 1 and 2 had similar MACCEs (10.1% versus 8.1%; adjusted hazard ratio [HR]=0.91, 95% confidence interval [CI]=0.65-1.26; p=0.59), and patients receiving versus not receiving pretreatment also had similar MACCEs (7.1% versus 8.4%; adjusted HR=1.17, 95% CI=0.78-1.74; p=0.45). Limitations in this study included its single-center nature and the sample size. In addition, the unadjusted outcomes showed significantly more patients experiencing shock in the non-P2Y12 inhibitor treatment group, which the investigators noted should be interpreted with caution. They added that after excluding patients with cardiogenic shock, there was no numerical difference between patients who did and did not receive P2Y12 inhibitor pretreatment. Overall, no significant differences in MACCEs were found between patients who received P2Y12 inhibitor pretreatment versus patients who did not, and MACCEs were not comparatively improved in either group. George A. Stouffer, MD, Kevin A. Friede, MD and Joseph S. Rossi, MD, all of the University of North Carolina, Chapel Hill, wrote an accompanying editorial and discussed the controversial nature of P2Y12 inhibitor treatment. Timing of the treatment has been up for debate in multiple studies, they wrote. The editorialists described how the present study contributes to the growing data for pretreatment in STEMI patients, but there are a lot of unanswered questions. “One is whether any subgroup benefits from early administration of P2Y12 inhibitors,” they wrote. “A second question is whether the antiplatelet effect can be enhanced by crushing the P2Y12 inhibitor. Current data do not support the superiority of pretreatment with P2Y12 inhibitors over catheterization laboratory administration in patients with STEMI. “However, there is no safety signal suggesting that pretreatment is harmful, and thus either strategy can be used on the basis of the available data,” the editorialists concluded. Sources: Rohla M, Ye SX, Shibutani H, et al. Pretreatment With P2Y12 Inhibitors in ST-Segment Elevation Myocardial Infarction: Insights From the Bern-PCI Registry. JACC: Cardiovasc Interv. 2023;17:17-28. Stouffer GA, Friede KA, Rossi JS. Pretreating With P2Y12 Inhibitors in STEMI: Does It Make Any Difference? JACC: Cardiovasc Interv. 2023;17:29-31. Image Credit: SasinParaksa – stock.adobe.com