非 ST 段抬高型急性冠状动脉综合征的 P2Y12 抑制剂预处理:NCDR胸痛-MI登记处

IF 21.7 1区 医学 Q1 CARDIAC & CARDIOVASCULAR SYSTEMS Journal of the American College of Cardiology Pub Date : 2024-11-15 DOI:10.1016/j.jacc.2024.09.1227
Hiroki A. Ueyama, Kevin F. Kennedy, Jennifer A. Rymer, Alexander T. Sandhu, Toshiki Kuno, Frederick A. Masoudi, John A. Spertus, Shun Kohsaka
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引用次数: 0

摘要

背景虽然有报道称非 ST 段抬高型急性冠状动脉综合征(NSTE-ACS)的 P2Y12 抑制剂预处理(定义为冠状动脉造影术前用药)率很高,但当代美国的实践模式并没有得到很好的研究。方法分析美国国家心血管数据登记处胸痛-心肌梗死(MI)登记中因 NSTE-ACS 而接受早期有创策略(到达后 24 小时内进行冠状动脉造影)的连续患者。对 2013 年 1 月 1 日至 2023 年 3 月 31 日期间的完整队列进行了时间趋势分析。随后,我们使用具有完整变量集的较新队列(2019 年 1 月 1 日至 2023 年 3 月 31 日)构建了分层回归模型,以量化不同操作者和机构在使用预处理方面的差异。对于这一当代队列,以操作者偏好为工具进行了工具变量分析,以比较接受预处理和未接受预处理患者的院内预后。结果P2Y12抑制剂预处理的使用率从2013Q1的24.8%降至2023Q1的12.4%。在当代的 110,148 名患者队列(2019-2023 年;平均年龄为 63.9 ± 12.5 岁;33.0% 为女性)中,有 17,509 人(15.9%)接受了预处理。观察到 P2Y12 抑制剂预处理存在显著差异(范围:0%-100%):分层回归模型显示,2 名相似患者在接受随机操作者或机构预处理的几率与接受其他操作者或机构预处理的几率相比,会有 >3倍的差异(中位数 OR:分别为 3.74 [95% CI: 3.57-3.91] 和 3.63 [95% CI: 3.51-3.74])。工具变量分析显示,院内全因死亡(1.5% vs 1.7%;P = 0.07)、复发性心肌梗死(0.6% vs 0.6%;P = 0.98)或大出血(2.7% vs 2.8%;P = 0.98)与预处理无显著差异。结论在一项美国全国性登记中,我们观察到 NSTE-ACS 患者在使用 P2Y12 抑制剂预处理方面存在显著差异。鉴于P2Y12抑制剂缺乏明显优势且可能导致住院时间延长,我们的研究结果凸显了提高标准化的重要性。
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P2Y12 Inhibitor Pretreatment in Non–ST-Segment Elevation Acute Coronary Syndrome: The NCDR Chest Pain-MI Registry

Background

Although high rates of P2Y12 inhibitor pretreatment (defined as the administration before coronary angiography) for non–ST-segment elevation acute coronary syndrome (NSTE-ACS) have been reported, contemporary U.S. practice patterns are not well studied.

Objectives

The goal of this study was to investigate the temporal U.S. trends, variability, and clinical outcomes of P2Y12 inhibitor pretreatment in NSTE-ACS.

Methods

Consecutive patients who underwent early invasive strategy for NSTE-ACS (coronary angiography ≤24 hours of arrival) in the National Cardiovascular Data Registry Chest Pain-Myocardial Infarction (MI) Registry were analyzed. A time-trend analysis was conducted on a complete cohort between January 1, 2013, and March 31, 2023. Subsequently, a more recent cohort (January 1, 2019, to March 31, 2023) with a complete set of variables was used to construct hierarchical regression models to quantify the variability in the use of pretreatment among operators and institutions. For this contemporary cohort, instrumental variable analysis, with operator preference as the instrument, was performed to compare the in-hospital outcomes between patients who received pretreatment and those who did not.

Results

Use of P2Y12 inhibitor pretreatment decreased from 24.8% in 2013Q1 to 12.4% in 2023Q1. Among the contemporary cohort of 110,148 patients (2019-2023; mean age 63.9 ± 12.5 years; 33.0% female), 17,509 (15.9%) received pretreatment. Significant variability in P2Y12 inhibitor pretreatment was observed (range: 0%-100%): hierarchical regression model demonstrated that 2 similar patients would have a >3-fold difference in the odds of pretreatment from 1 random operator or institution as compared with another (median OR: 3.74 [95% CI: 3.57-3.91] and 3.63 [95% CI: 3.51-3.74], respectively). Instrumental variable analysis demonstrated no significant differences in in-hospital all-cause death (1.5% vs 1.7%; P = 0.07), recurrent MI (0.6% vs 0.6%; P = 0.98), or major bleeding (2.7% vs 2.8%; P = 0.98) with pretreatment. However, in patients who underwent coronary artery bypass surgery, pretreatment was associated with a longer length of stay (11.2 ± 5.1 days vs 9.8 ± 5.0 days; P < 0.01).

Conclusions

In a national U.S. registry, we observed significant variability in the use of P2Y12 inhibitor pretreatment among NSTE-ACS patients. Given the lack of clear advantages and the potential for prolonged hospital stays, our findings highlight the importance of efforts to improve standardization.
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来源期刊
CiteScore
42.70
自引率
3.30%
发文量
5097
审稿时长
2-4 weeks
期刊介绍: The Journal of the American College of Cardiology (JACC) publishes peer-reviewed articles highlighting all aspects of cardiovascular disease, including original clinical studies, experimental investigations with clear clinical relevance, state-of-the-art papers and viewpoints. Content Profile: -Original Investigations -JACC State-of-the-Art Reviews -JACC Review Topics of the Week -Guidelines & Clinical Documents -JACC Guideline Comparisons -JACC Scientific Expert Panels -Cardiovascular Medicine & Society -Editorial Comments (accompanying every Original Investigation) -Research Letters -Fellows-in-Training/Early Career Professional Pages -Editor’s Pages from the Editor-in-Chief or other invited thought leaders
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