The management of non-ST elevation - acute coronary syndrome (NSTE-ACS) remains a critical area of focus, particularly regarding the optimal use of antiplatelet therapy. The study conducted through the REal-world ADoption Survey on Acute antiPlatelet Treatment (READAPT) sheds light on several important issues in the current practice of NSTE-ACS management, including the timing of invasive coronary angiography (CAG), the application of pretreatment with P2Y12 inhibitors, and the adherence to European Society of Cardiology (ESC) guidelines. The findings, particularly with respect to Türkiye, provide a valuable perspective on both adherence to guidelines and the practical challenges faced in daily clinical practice.
A key observation from the survey was the widespread use of pre-treatment with oral P2Y12 inhibitors, despite the ESC guidelines suggesting that this is not recommended in routine clinical practice before the coronary anatomy is determined.[1] This discrepancy between guidelines and clinical practice is seen not only in Turkey but also across Europe, where a substantial proportion of patients receive pre-treatment before angiographic confirmation.[2, 3] While this approach is common, it raises concerns about the risk of bleeding, particularly in patients who may require coronary artery bypass surgery or those with specific clinical characteristics. The potential for adverse outcomes, such as bleeding complications, further emphasizes the need for careful risk stratification when deciding on pretreatment strategies.
A web-based survey focusing on the diagnosis, medical treatment, and invasive management of NSTE-ACS was created based on a literature review. The questionnaire was accessible on a dedicated online platform from February 4, 2022, to April 15, 2022. The participating countries were Austria, Belgium, the Czech Republic, Denmark, Finland, France, Germany, Greece, Italy, Norway, Slovenia, Spain, Sweden, Switzerland, the Netherlands, Turkey, and the United Kingdom.
Interestingly, despite the non-recommendation for pretreatment, ticagrelor has emerged as the most frequently used P2Y12 inhibitor, followed by clopidogrel and prasugrel. This highlights an ongoing clinical preference for ticagrelor in many centers, potentially driven by its superior pharmacodynamics and faster onset of action compared to clopidogrel.[4] The use of intravenous P2Y12 inhibitors, such as cangrelor, remains relatively low across the board, including in Turkey, where fewer than 10% of patients receive such treatment. This is in line with the lack of direct evidence comparing cangrelor with other oral agents like prasugrel and ticagrelor in NSTE-ACS populations, despite their established efficacy in percutaneous coronary intervention (PCI) settings.[5]
Additionally, the survey underscores regional variations in the timing of invasive procedures, particularly the timing of CAG and PCI. In Turkey, a high proportion of patients (96%) undergo invasive angiography within 24 hours, which is consistent with the recommendations for early intervention in high-risk patients with NSTE-ACS. These findings further reinforce the importance of timely intervention for improving outcomes, as early revascularization remains a cornerstone in reducing mortality and preventing complications.
However, the study also highlighted significant socioeconomic and geographic disparities, particularly among patients in rural areas where healthcare access is limited. These disparities are associated with delayed presentation and consequently worse outcomes. The impact of socioeconomic factors on healthcare delivery should not be underestimated because they can directly affect treatment timeliness and the use of advanced therapies like mechanical circulatory support. Addressing these inequalities should be a priority for healthcare systems so as to ensure that all patients, regardless of their background, have equitable access to optimal care.
In conclusion, while the READAPT survey provides valuable insights into current practices in NSTE-ACS management, it also highlights the gaps between guideline recommendations and clinical practices, particularly regarding pretreatment strategies. The need for greater adherence to evidence-based guidelines, along with consideration of individual patient risk factors, remains critical for improving patient outcomes. Additionally, efforts to address healthcare access disparities, especially in underserved areas, could significantly improve survival rates and reduce the burden of this serious condition.
