P2Y12-inhibitors in NSTEMI - old and new guidelines

Focus on

Needs assessments:
The new ESC Clinical Practice Guidelines on NSTEMI recommend prasugrel over ticagrelor in ACS patients referred for percutaneous coronary intervention (PCI). At the same time these guidelines recommend using prasugrel only after the coronary anatomy is known and avoiding pre-cathlab use of P2Y12-inhibitors. Does this change clinical routine essentially, as :

1. In many systems of ACS care, high-risk ACS patients cannot be treated by PCI with 24 hours of diagnosis and are therefore frequently pre-treated with ticagrelor or clopidogrel
2. Patients with ACS but without indication for PCI frequently receive ticagrelor for a conservative strategy
3. In ACS-patients with high or very high bleeding risk clopidogrel and in patients without increased bleeding risk ticagrelor have been tested for short DAPT (1-3 months) followed by P2Y12-inhibtor monotherapy with significant reduced bleeing hazards but similar ischemic outcome. No data are currently available for the use of prasugrel in this strategy.

Learning objectives

• recognise the correct use of P2Y12-inhibtors (ticagrelor and prasugrel) in patients presenting with non-ST-elevation ACS
• implement the new non-ST-elevation ACS guidelines in clinical practice
• manage new indications for ticagrelor in ACS patients, namely as monotherapy after short duration of DAPT