Is Pretreatment With Platelet Inhibitors Beneficial or Harmful For Acute Coronary Syndrome? Interview with:
Anne Bellemain-Appaix
Service de Cardiologie-La Fontonne Hospital, Antibes, France and

Gilles Montalescot Professor of  Cardiology
Institut de CardiologiePitié-Salpêtrière Hospital
Université Paris 6, France
ACTION Study Group, Paris, France

Medical Research: What is the background for this study?

Response: Pretreatment with P2Y12 inhibitors for Non-ST-Elevation Acute Coronary Syndrome (NSTE-ACS) patients, although advised in current guidelines, has been recently questioned in term of benefit/risk ratio (no ischemic benefit and increase in major bleeding). We wanted to answer this question by giving enough power to results in a complete meta-analysis of studies comparing P2Y12 inhibitors pretreatment (defined as its administration before the coronary angiogram) to no pretreatment in NSTE-ACS.

Medical Research: What are the main findings?

Response: The results for all cause mortality, major bleeding, and major adverse cardiovascular events are summarized in the figure for all patients with non-ST elevation Acute Coronary Syndrome and for those managed by PCI. Stent thrombosis, stroke, and urgent revascularization did not differ between groups (pretreatment vs no pretreatment). The results were consistent for both thienopyridines (clopidogrel and prasugrel) and were confirmed in sensitivity analyses (according to clopidogrel loading dose, in randomised trials only, and after the exclusion of the old CURE study).

Medical Research: What should clinicians and patients take away from your report?

Response: This systematic review and meta-analysis shows that in patients with non-ST elevation ACS, pretreatment with thienopyridines is not associated with a lower risk of mortality globally or more specifically in patients undergoing PCI. The reduction of ischemic endpoints is modest and counterbalanced by an increase in major bleeding, no matter the final management strategy, with or without PCI.

The concept of systematic and immediate pretreatment with P2Y12 antagonists in patients admitted with non-ST elevation Acute Coronary Syndrome needs to be reconsidered in daily practice and in guidelines

Medical Research: What recommendations do you have for future research as a result of this study?

Response: We think that similar prospective and randomized controlled trials should be performed with ticagrelor in NSTE-Acute Coronary Syndrome patients sheduled or not to PCI, and not pre-treated  before randomization. The PLATO study cannot answer the question of pretreatment for ticagrelor.

We should try to identify better the patients who absolutely need to be pretreated before a scheduled angiogram. However subgroup analyses in the ACCOAST study do not really help as the absence of benefit was observed consistently across subgroups. The bleeding excess also occurred across the board.

The role of IV drugs like cangrelor and GP IIbIIIa inhibiotrs needs also to be reconsidered in the light of the new information published in this metaanalysis.


Bellemain-Appaix Anne, Kerneis Mathieu, O’Connor Stephen A, Silvain Johanne, Cucherat Michel, Beygui Farzin et al. Reappraisal of thienopyridine pretreatment in patients with non-ST elevation acute coronary syndrome: a systematic review and meta-analysis
BMJ 2014; 349:g6269


Last Updated on October 30, 2014 by Marie Benz MD FAAD