According to the recent guidelines from the European Society of Cardiology,1 an invasive strategy should be performed within the first 24 hours from diagnosis in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) at high risk; and a very early invasive strategy (<2 hours) deserves only to those patients at very high risk. The question of the optimal timing of the invasive procedure is however still a matter of debate. In this context, the absence of P2Y12 inhibitor (P2Y12i) pretreatment may impact the decision. Indeed, in the absence of P2Y12i pretreatment, recurrent ischaemic events may occur more frequently pending the coronary revascularisation and may subsequently have a deleterious effect on patient outcome. In recent guidelines,1 routine P2Y12i pretreatment is not recommended (class III-A) if early invasive management is planned (<24 hours), but pretreatment may be considered if early invasive strategy is not possible and the patient is not at high risk of bleeding (class IIb-C).
In the past, several trials have tried to answer this critical question. In a meta-analysis published in 2016, it was observed that a very early strategy is associated with a reduction in recurrent ischaemia or refractory angina and a shorter in-hospital stay but has no significant impact on mortality.2 The year after, another meta-analysis confirmed the lack of benefit of a very early strategy on all-cause mortality, but …
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- Source: http://heart.bmj.com/cgi/content/short/110/7/461?rss=1