Pre-treatment with an oral P2Y
12 receptor inhibitor in addition to aspirin is defined by its administration to every patient before coronary angiography, which will (or not) confirm the diagnosis of non–ST-segment elevation acute coronary syndromes (NSTE-ACS) and indicate (or not) whether percutaneous coronary intervention (PCI) can be performed. Both confirmation of the diagnosis and PCI treatment occur in only 65% of patients carefully selected in randomized clinical trials and in even less patients represented in real-life registries. Intuitively, pre-treatment is appealing for these 65% of patients, as early administration would guarantee enough time for these oral antiplatelet agents to achieve optimal antiplatelet effect during and immediately after PCI and would thereby possibly provide better protection against PCI-related thrombotic complications. The other 35% heading to the catheterization laboratory may expect harm more than benefit, as they would be overtreated in case of misdiagnosis (aortic dissection, myopericarditis, heart failure, hypertension, gastric ulcer, pulmonary embolism, and so on) or be exposed unnecessarily to a risk of perioperative bleeding when heading to the operating room for an emergent CABG. We are looking back on 20 years of debate on the issue of pre-treatment in NSTE-ACS, and it is probably time to turn this page; however, first, let us answer the key questions for the clinicians.
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Thus, the time has come for a definite change in recommendations and practice about pre-treatment in NSTE-ACS. There is nothing dubious about it, pre-treatment is not effective and potentially harmful, and this is a class effect. We shall be better safe than sorry with our patients.
