Copyright © 2002 by the European Society of Cardiology.
Patients with acute coronary syndromes without persistent ST elevation undergoing percutaneous coronary intervention benefit most from early intervention with protection by a glycoprotein IIb/IIIa receptor blocker
a University Hospital Rotterdam, Rotterdam, The Netherlands
b Duke Clinical Research Institute, Durham, North Carolina, U.S.A.
c Cleveland Clinic Foundation, Cleveland, Ohio, U.S.A.
d Bristol Heart Institute, Bristol, U.K.
e Baylor College of Medicine and the Methodist Hospital, Houston, Texas, U.S.A.
f Tenon Hospital, Paris, France
revised April 9, 2001; accepted April 11, 2001
Abstract
Background Many patients with acute coronary syndromes are offered percutaneous coronary intervention. However, the appropriate indications for, and optimal timing of, such procedures are uncertain. We analysed timing of intervention and associated events (death and myocardial infarction) in the PURSUIT trial in which 9461 patients received a platelet glycoprotein IIb/IIIa inhibitor, eptifibatide, or placebo for 72h. Other treatment was left to the investigators. 2430 patients underwent percutaneous coronary intervention within 30 days. Four groups were distinguished, who underwent percutaneous coronary intervention on day 1; on days 2 or 3; at 4 to 7 days; or between 8 until 30 days, for eptifibatide- and placebo-treated patients.
Results The four groups treated with placebo demonstrated total 30-day events of 15·9% for day 1 percutaneous coronary intervention, 17·7%, 15·0% and 18·2%, respectively, for successive intervals of later intervention. Later intervention was associated with more pre-procedural events (2·2% to 13·7%, P=0·001) which was balanced by a decrease in procedure-related events (12·1 to 3·1%, P=0·001), while the overall 30-day event rates were similar. Eptifibatide-treated patients with percutaneous coronary intervention on day 1 had the lowest rate of 30-day events (9·2%, P<0·05 vs other groups). In this group, pre-procedural risk was only 0·3%, while percutaneous coronary intervention on eptifibatide treatment was associated with low procedural risk (7·2%). The total 30-day event rate for later percutaneous coronary intervention in patients receiving eptifibatide was 14·0 on days 2 and 3, 15·0% for days 4 to 7 and 17·4% for days 7 to 30, respectively.
Conclusion Patients treated with a platelet glycoprotein IIb/IIIa receptor blocker, and early percutaneous coronary intervention (within 24h) had the lowest event rate in this post hoc analysis. Thus ‘watchful waiting’ may not be the optimal strategy. Rather an early invasive strategy with percutaneous coronary intervention under protection of a platelet glycoprotein IIb/IIIa receptor blocker should be considered in selected patients. Randomized trials are warranted to verify this issue.
Key Words: Acute coronary syndromes, revascularization, unstable angina pectoris, platelet aggregation inhibitors, eptifibatide, myocardial infarction
f1 Correspondence: Prof Maarten L. Simoons, University Hospital Rotterdam, Thoraxcenter Cardiology, room H560, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
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