Revascularization with coronary artery bypass grafting in non-ST-elevation acute coronary syndromes: A snapshot of randomized trials and registries

A recent European Society of Cardiology (ESC) guidelines for the management of patients presenting with acute coronary syndromes (ACS) without persistent ST-segment elevation (NSTE-ACS) do not recommend routine pretreatment with a P₂ Y₁₂ receptor antagonist in patients in which the coronary anatomy is undetermined, and early invasive management is planned (class recommendation III, level of evidence A). The rationale for such recommendation was mainly based on the results obtained from two large randomized trials, ACCOAST and ISAR-REACT 5, and analysis from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) showing that administration of P₂ Y₁₂ inhibitor before the knowledge of coronary anatomy in patients with NSTE-ACS did not improve ischemic outcomes and significantly increased risk of bleeding. In this work, we deliberately analyzed data from pivotal randomized trials that changed clinical practice, cited in the official document, and on which the ESC guideline recommendation was dominantly based. We then analyzed relevant real-world data (derived from international registries or observational studies representing clinical practice in different regions of the world)