Timing of Oral P2Y12 Inhibitor Administration in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome

The optimal timing of oral P2Y12 inhibitors administration is not well-defined even though they remain the main-stay treatment in the management of patients with non–ST-segment elevation acute coronary syndrome. In the theoretical knowledge, administration of an oral P2Y12 inhibitor before defining coronary anatomy provides more ischemic protection while patients are waiting to undergo coronary angiography and reduces the risk of periprocedural thrombotic complications among those undergoing percutaneous coronary interventions. A randomized, adaptive, open-label, multicentre clinical trial was conducted that included 1,449 patients. These patients were randomized to downstream or upstream oral P2Y12 inhibitor administration. The patients were randomly assigned to receive pre-treatment with ticagrelor before angiography (upstream group) or no pre-treatment (downstream group). In the downstream group, the patients were further randomized to receive ticagrelor or prasugrel. The authors of this study hypothesised that downstream strategy has an upper hand over upstream strategy on the combination of efficacy and safety events. The results of this study demonstrates that there was no significant difference between downstream and upstream groups in terms of primary endpoint, a composite of death due to vascular causes; nonfatal myocardial infarction or nonfatal stroke. These results were confirmed w.r.t patients undergoing percutaneous coronary intervention and regardless of the timing of coronary angiography. In conclusion, downstream and upstream oral P2Y12 inhibitor administration strategies were found to be associated with low incidence of ischemic and bleeding events and minimal difference in terms of numerical values were found between the groups. Disclaimer: Lupin makes no representation or warranty of any kind, expressed or implied, regarding the accuracy, adequacy, validity, reliability, availability, or completeness of any scientific information shared by the HCP on the ­­­STAR UPDATE podcast. You should not allow the contents of this to substitute for your own medical judgment, which you should exercise in evaluating the information on this website.