The Efficiency And Safety Of Pretreatment With Oral P2Y12 Inhibitors Before Percutaneous Coronary Intervention In Non-ST-segment Elevation Acute Coronary Syndrome Patients: A Systematic Review And Meta Analysis

Objective:pretreatment with oral P2Y12 inhibitors in patients with non-ST segment elevation acute coronary syndrome(NSTEACS)is still common in clinical practice.Pretreatment is generally defined as administration of P2Y12 inhibitors before angiography(Coronary Angiography,CAG)to achieve a certain degree of platelet inhibition.Pretreatment is not recommended in 2020ESC guidelines for patients with NSTEMI-ACS whose coronary anatomy is not clear.This is not consistent with the routine use of P2Y12 inhibitors load before PCI(for example,300mg clopidogrel before operation).The primary purpose of this paper is to systematically evaluate the effects of oral P2Y12 inhibitor pretreatment before PCI on major adverse cardiovascular outcomes and major hemorrhage outcomes in patients with NSTE-ACS,and to provide evidence for the application of P2Y12 inhibitor preconditioning before PCI in NSTE-ACS patients.The second purpose of this paper is to systematically evaluate the safety of common P2Y12 inhibitors such as clopidogrel,ticagrelor and prasugrel,also to provide evidences for patients to choose P2Y12 inhibitors.Methods:MEDLINE,Pub Med,Embase,Web of Science,the Cochrane Central Register for Controlled Trials were searched.The primary effect endpoint and safety endpoint were Major adverse cardiovascular events and major bleeding,respectively,all-cause death and myocardial infarction were also analyzed.Newcastle-Ottawa(NOS)scale was used to evaluate the bias risk of non-randomized controlled trials.Cochrane risk bias assessment tool was used to evaluate the included randomized controlled trials.Finally,the data are extracted for Meta analysis.Results:the meta-analysis of pre-PCI pretreatment in NSTE-ACS patients was finally included 7 non-randomized controlled studies with NOS scores of more than 6 stars,while 7 RCT studies with cochrane risk bias assessment tools showed high quality.Most of the non-randomized controlled trials included in this study were inherently biased.The results of separate analysis of randomized controlled trials showed that 7 randomized controlled trials included 13226 patients,of which 6603were assigned to P2Y12 inhibitor pretreatment group and 6623 to non-preconditioning group.The average age was 63.5 years old,and there were 3598women(27.2%).Pretreatment was not associated with a reduction in 30-day MACE(odds ratio[OR],0.95;95%CI,0.78-1.15;I~2=28%),30-day MI(OR,0.90;95%CI,0.72-1.12;I~2=19%),or 30-day cardiovascular death(OR,0.79;95%CI,0.49-1.27;I~2=0%).The risk of 30-day major bleeding was increased among patients who underwent pretreatment(OR,1.51;95%CI,1.16-1.97;I~2=41%).The number needed to harm to bring about 1 major bleeding event with oral P2Y12 inhibitor pretreatment was 63 patients.Conclusion:In this study,pretreatment with oral P2Y12 inhibitors among patients with NSTEACS prior to angiography,compared with treatment once coronary anatomy is known,was associated with increased bleeding risk and no difference in cardiovascular outcomes.Routine pretreatment with oral P2Y12 inhibitors in patients with NSTEACS receiving an early invasive strategy is not supported by this study.