Dual Antiplatelet Pretreatment Comparison among Non-ST-Elevation Myocardial Infarction Patients

Abstract

To the Editor, We read with great interest the article by Sheikh et al. [1], “Dual Antiplatelet Pretreatment Comparison among Non-ST-Elevation Myocardial Infarction Patients,” which provides valuable insights into the management of NSTEMI in resource-limited settings. The comparison between clopidogrel and ticagrelor as pretreatment agents is both clinically relevant and timely. To further strengthen such investigations in the future, it would be beneficial to incorporate patient-reported outcomes—particularly health-related quality of life (HRQOL) measures—which have become increasingly important in assessing post-intervention recovery beyond conventional clinical endpoints. Evidence from multicenter registries demonstrates that NSTEMI patients, especially women, often report poorer HRQOL than their STEMI counterparts [2]. Inclusion of these outcomes could enhance the study’s translational and patient-centered relevance. Additionally, subgroup analyses based on age and gender may help identify clinically significant variations. Non-typical symptom presentation is more frequent among women and elderly patients, and gender-specific differences in outcomes and treatment patterns have been documented globally. Data from Pakistani PCI registries have also shown higher unadjusted mortality rates in women that normalize after adjustment for comorbidities [3]. Such analyses could inform more equitable and tailored management strategies. The study also notes an increased bleeding rate in the pretreatment arm but does not specify timing of antiplatelet administration, particularly in patients proceeding to coronary artery bypass grafting (CABG). Trials such as ACCOAST have shown that early administration of prasugrel prior to angiography increased bleeding risk without improving ischemic outcomes [4]. Future research may benefit from protocolized timing strategies to optimize clinical recommendations. Finally, while in-hospital outcomes provide valuable short-term data, long-term follow-up is essential to evaluate the sustained safety and efficacy of dual antiplatelet therapy. Extended monitoring of major adverse cardiovascular events (MACE) and post-discharge bleeding would better inform long-term management, particularly in high-risk populations [5]. References Sheikh KU, Sarfaraz A, Anwar MW, Batool N, Ahmed N, Khan S. Dual antiplatelet pretreatment comparison among non-ST-elevation myocardial infarction patients. Pak Heart J. 2025;58(2):168-75. DOI: 10.47144/phj.v58i2.2974 Kim MJ, Jeon DS, Gwon HC, Kim SJ, Chang K, Kim HS, et al. Health-related quality of life after percutaneous coronary intervention in patients with UA/NSTEMI and STEMI: the Korean multicenter registry. J Korean Med Sci. 2013;28(6):848-54. DOI: 10.3346/jkms.2013.28.6.848. Kovacic JC, Mehran R, Karajgikar R, Baber U, Suleman J, Kim MC, et al. Female gender and mortality after percutaneous coronary intervention: results from a large registry. Catheter Cardiovasc Interv. 2012;80(4):514-521. DOI: 10.1002/ccd.23338 Montalescot G, Bolognese L, Dudek D, Goldstein P, Hamm C, Tanguay JF, et al. ACCOAST Investigators. Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N Engl J Med. 2013;369(11):999-1010. DOI: 10.1056/NEJMoa1308075 ErtaÅŸ FS, Tokgozoglu L; EPICOR Study Group. Long-term follow-up of antithrombotic management patterns in acute coronary syndrome patients. Turk Kardiyol Dern Ars. 2018;46(3):175-83. DOI: 10.5543/tkda.2017.66724