Gilles Montalescot

Immediate vs Delayed Intervention for Acute Coronary Syndromes: A Randomized Clinical Trial

CONTEXTnInternational guidelines recommend an early invasive strategy for patients with high-risk acute coronary syndromes without ST-segment elevation, but the optimal timing of intervention is uncertain.nnnOBJECTIVEnTo determine whether immediate intervention on admission can result in a reduction of myocardial infarction compared with a delayed intervention.nnnDESIGN, SETTING, AND PATIENTSnThe Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD) study, a randomized clinical trial that assigned, from August 2006 through September 2008 at 13 centers in France, 352 patients with acute coronary syndromes without ST-segment elevation and a Thrombolysis in Myocardial Infarction (TIMI) score of 3 or more to receive intervention either immediately or on the next working day (between 8 and 60 hours after enrollment).nnnMAIN OUTCOME MEASURESnThe primary end point was the peak troponin value during hospitalization; the key secondary end point was the composite of death, myocardial infarction, or urgent revascularization at 1-month follow-up.nnnRESULTSnTime from randomization to sheath insertion was 70 minutes with immediate intervention vs 21 hours with delayed intervention. The primary end point did not differ between the 2 strategies (median [interquartile range] troponin I value, 2.1 [0.3-7.1] ng/mL vs 1.7 [0.3-7.2] ng/mL in the immediate and delayed intervention groups, respectively; P = .70). The key secondary end point was observed in 13.7% (95% confidence interval, 8.6%-18.8%) of the group assigned to receive immediate intervention and 10.2% (95% confidence interval, 5.7%-14.6%) of the group assigned to receive delayed intervention (P = .31). The other end points, as well as major bleeding, did not differ between the 2 strategies.nnnCONCLUSIONnIn patients with acute coronary syndromes without ST-segment elevation, a strategy of immediate intervention compared with a strategy of intervention deferred to the next working day (mean, 21 hours) did not result in a difference in myocardial infarction as defined by peak troponin level.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00442949.

Measures of Platelet Activation and Aggregation

Platelets play a key role in the pathophysiology of cardiovascular disease. Disrupting platelet activation and aggregation with antiplatelet agents is effective both for primary and secondary prevention of atherothrombotic events, and has become a cornerstone of cardiovascular disease management nowadays. Identifying hyperactive platelets as predictors of a thrombotic tendency and monitoring the response to antiplatelet agents have become the key objectives of platelet function monitoring. We have learned more about the variable response to antiplatelet drugs as more accurate and reliable platelet function assays have been developed. However, there are currently no data establishing a cause-and-effect relationship or allowing for the establishment of an algorithm for treatment in response to measured platelet function inhibition.

La gestion de l’arrêt des antiagrégants plaquettaires : un véritable enjeu médical

Les antiagregants plaquettaires constituent la pierre angulaire du traitement de prevention secondaire de la maladie atherothrombotique. Leur interruption est une situation frequente qui expose au risque de recidive d’accident arteriel aigu comme cela est bien etabli en cas de mauvaise compliance. L’interruption temporaire dans le contexte d’une anesthesie est une situation beaucoup plus frequente ou il convient d’analyser le rapport benefice risque de cette strategie. En l’absence de donnees prospectives solides, le bon sens doit permettre une gestion efficace dans la majorite des cas, notamment en s’aidant des avis d’experts. Les elements les plus importants a prendre en compte dans cette discussion sont le delai entre l’interruption et l’evenement qui a motive la mise en route du traitement antiagregant et le nombre de traitements antiagregants arretes. Cette reflexion doit remplacer le rituel de l’arret systematique avec substitution.