CLINICAL STUDY
Early angioplasty in acute coronary syndromes without persistent st-segment elevation improves outcome but increases the need for six-month repeat revascularization
An analysis of the pursuit trial
Eelko Ronner, MD, PhD* ,
Eric Boersma, PhD*,
Gert-Jan Laarman, MD, PhD,
G. Aernout Somsen, MD, PhD ,
Robert A. Harrington, MD, PhD ,
Jaap W. Deckers, MD, PhD*,
Eric J. Topol, MD, PhD||,
Robert M. Califf, MD, PhD and
Maarten L. Simoons, MD, PhD*,*
* University Hospital Rotterdam, Rotterdam, The Netherlands
Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
Academic Medical Center, Amsterdam, The Netherlands
Duke Clinical Research Institute, Durham, North Carolina, USA
|| Cleveland Clinic Foundation, Cleveland, Ohio, USA
Manuscript received September 5, 2001;
revised manuscript received March 5, 2002,
accepted March 27, 2002.
* Reprint requests and correspondence: Dr. Maarten L. Simoons, Thoraxcenter, H560, Academisch Ziekenhuis Rotterdam, Dijkzigt, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
simoons{at}tch.fgg.eur.nl
OBJECTIVES: We explored the effect of timing of percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS) without persistent ST-segment elevation on the need for repeat revascularization, and we related this effect to other events.
BACKGROUND: Percutaneous coronary intervention is widely used to treat ACS without persistent ST-segment elevation. Moreover, restenosis and subsequent revascularization after PCI are more frequent in ACS than in stable angina. The optimal timing of PCI in ACS without persistent ST-segment elevation is unknown.
METHODS: In the Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) database, patients were stratified by the time of PCI. In the PURSUIT trial, 9,461 patients received a platelet glycoprotein IIb/IIIa inhibitor, eptifibatide or placebo for 72 h. The investigators decided on other treatments.
RESULTS: A total of 2,430 patients underwent PCI within 30 days. Repeat revascularization (during 165 days) was notably higher for PCI within 24 h of enrollment (n = 620 [19%]) than for PCI at 24 to 72 h (n = 624 [16.7%]), 3 to 7 days (n = 614 [13.2%]), or 8 to 30 days (n = 561 [7.7%]; p < 0.001), regardless of eptifibatide use. This gradual reduction in the revascularization rate for later PCI was also observed after multivariate analysis correcting for baseline characteristics and with time as a continuous variable.
CONCLUSIONS: Percutaneous coronary intervention within 24 is associated with improved outcome (other analysis) but more repeat revascularization. Prospective analyses are needed to test the hypothesis that rapid PCI in ACS with a platelet glycoprotein IIb/IIIa receptor antagonist reduces myocardial infarction (and possibly death) and is therefore most suited for patients at highest risk of infarction, despite a higher need for repeat revascularization.
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Abbreviations and Acronyms
| | ACS | | acute coronary syndromes | | CAPTURE | | Chimeric c7E3 AntiPlatelet Therapy in Unstable angina REfractory to standard treatment trial | | CK-MB | | creatine kinase, MB fraction | | FRISC | | FRagmin during InStability in Coronary artery disease | | GP | | glycoprotein | | MI | | myocardial infarction | | PCI | | percutaneous coronary intervention | | PURSUIT | | Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy | | TACTICS/TIMI-18 | | Treat Angina with aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy/Thrombolysis in Myocardial Infarction trial |
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