Abstract Body (Do not enter title and authors here): Background
Acute coronary syndrome (ACS) is the leading cause of heart disease, resulting in over 300,000 deaths annually. The 2014 ACC/AHA guideline recommends a loading dose of a P2Y12 receptor inhibitor prior to PCI with stenting (Class IA).

Objective
This study aims to evaluate the risks and benefits of upstream loading of P2Y12 inhibitors in ACS patients.

Methodology
We retrospectively analyzed the charts of all ACS patients over 18 years old admitted to our community hospital in Michigan from August 2022 to July 2023. Exclusion criteria included patients with type II NSTEMI, hypersensitivity to P2Y12 inhibitors, active bleeding, hemoglobin levels less than 7 g/dl, those already on P2Y12 inhibitors, and pregnant patients.

Results
Out of 518 patients reviewed, 399 were included in the study. Among 285 NSTEMI patients, 89.5% were not loaded with P2Y12 inhibitors in the ED, while 10.5% were. In the loaded group, 3% underwent CABG, 90% required PCI, and 6% received medical treatment. In the non-loaded group, 12.5% underwent CABG, one patient had an aortic dissection, and 53.8% and 33.7% required PCI and medical treatment, respectively. Among 114 STEMI patients, 74.5% were not loaded with P2Y12 inhibitors in the ED, while 25.5% were. In the loaded group, 100% required PCI. In the non-loaded group, 8.2% underwent CABG, and 92% required PCI.

Conclusion
Our real-world data from a community hospital indicate that most ACS patients benefit from P2Y12 loading, with only a minority experiencing adverse effects. To address this, we plan to collaborate with our information technology department to implement reminders for ED physicians to consult with cardiologists about P2Y12 inhibitor loading in ACS patients.