Clinical outcomes for prasugrel versus clopidogrel in patients with unstable angina or non-ST-elevation myocardial infarction: an analysis from the TRITON-TIMI 38 trial.

AIMS: In the Trial to assess Improvement in Therapeutic Outcomes by optimizing platelet inhibitioN with prasugrel Thrombolysis In Myocardial Infarction 38 (TRITON-TIMI 38), prasugrel reduced the primary ischaemic endpoint as compared with clopidogrel in acute coronary syndrome (ACS) patients planned to undergo percutaneous coronary interventions, but increased the risk of bleeding. The present analysis shows the efficacy and safety data for the 10,074 non-ST segment elevation (NSTE)-ACS patients included in that trial. METHODS AND RESULTS: The primary endpoint was significantly reduced by prasugrel in the overall NSTE-ACS population (hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.73-0.93, p=0.002) as well as in unstable angina (UA) and in non-ST elevation myocardial infarction (NSTEMI) patient subgroups (interaction p value=0.39). Although non-coronary artery bypass graft (CABG) TIMI major bleeding was increased with prasugrel as compared with clopidogrel (HR 1.40, 95% CI 1.05-1.88, p=0.02), there was a net clinical benefit in patients assigned to prasugrel (HR 0.89, 95% CI 0.80-1.00, p=0.043), which was consistent for UA and NSTEMI subgroups (interaction p value=0.84 and 0.72). In patients who met the criteria for prasugrel use recommended by the European Medicines Agency, thus excluding from the analysis patients with prior transient ischemic attack (TIA)/stroke, with weight <60 kg or age ≥75 years, and censoring follow-up at 365 days, (European Union (EU)-label cohort) prasugrel showed superiority over clopidogrel with regard to the primary endpoint (HR 0.73, 95% CI 0.63-0.85, p<0.0001) for the entire NSTE-ACS population, as well as for UA patients and NSTEMI patients without significant differences in non-CABG TIMI major bleeding. CONCLUSION: Prasugrel, as compared with clopidogrel, significantly reduced the primary endpoint of the TRITON-TIMI 38 trial in NSTE-ACS patients, as well as in the UA and NSTEMI groups. A significant reduction in the primary endpoint without increased bleeding was observed in the EU-label cohort

Early invasive versus selectively invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: impact of age.

BackgroundIt is unclear whether the benefits of an early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) equally apply to younger and older individuals. Elderly patients are generally less likely to undergo EIS when compared with younger patients. ObjectivesWe conducted a meta-analysis to compare the benefit of an EIS versus a selectively invasive strategy (SIS) in patients with NSTEACS. We tested the hypothesis that the magnitude of benefit of an EIS over a SIS mainly applies to older individuals. MethodsWe extracted data from randomized controlled trials (RCTs) identified through search methodology filters. The primary outcome of the analysis was the composite of all-cause death and myocardial infarction (MI). Secondary outcomes were death and MI taken alone and re-hospitalization. ResultsNine trials (n=9,400 patients) were eligible. The incidence of the composite end-point of MI and all-cause death was 16.0% with the EIS and 18.3% with the SIS (OR: 0.85, 95% CI: 0.76-0.95). The incidence of MI was 8.4% with the EIS and 10.9% with the SIS (OR: 0.75, 95% CI: 0.66-0.87). Similar results were obtained for rehospitalization (OR: 0.71, 95% CI: 0.55-0.90). The incidence of all-cause death did not differ between the two groups. The EIS reduced the composite end-point and re-hospitalization to a greater extent in elderly than in younger patients (P for interaction=0.044 and <0.0001, respectively). These findings were confirmed in meta-regression analyses. ConclusionsIn patients with NSTEACS, a routine EIS reduces the risk of rehospitalization and the composite end point of recurrent MI and death to a greater extent in elderly than in younger individuals. (c) 2013 Wiley Periodicals, I

ABNORMAL CORONARY VASOCONSTRICTION AS A PREDICTOR OF RESTENOSIS AFTER SUCCESSFUL CORONARY ANGIOPLASTY IN PATIENTS WITH UNSTABLE ANGINA-PECTORIS

Background. High rates of restenosis after coronary angioplasty have been reported in patients with vasospastic angina. This study was designed to determine whether the occurrence of abnormal coronary vasoconstriction, detected by means of hyperventilation testing before angioplasty, influences the risk of restenosis after successful dilation. Methods. Hyperventilation testing was performed 0 to 4 days before coronary angioplasty in 106 consecutive patients with unstable angina and single-vessel coronary artery disease. Abnormal coronary vasoconstriction was considered present if hyperventilation-induced myocardial ischemia occurred during the recovery phase of the test. All patients had follow-up angiography 8 to 12 months after angioplasty. Results. Abnormal coronary vasoconstriction was observed in 48 patients (group 1), whereas 58 patients (group 2) had either a negative response throughout the test or a positive response only during the overbreathing phase of the hyperventilation test. Angioplasty was successful in 40 patients in group 1 and 51 in group 2. Restenosis was documented in 29 patients (73 percent) in group 1 and 13 (25 percent) in group 2 (relative risk of restenosis, 2.84; 95 percent confidence interval, 1.69 to 4.28; P < 0.001). In a multivariate analysis, the following three characteristics were independently related to the risk of restenosis (in descending order of importance): ST-segment elevation during spontaneous ischemic attacks (P < 0.001), hyperventilation-induced abnormal coronary vasoconstriction (P < 0.001), and the presence of a lesion more than 10 mm long in the left anterior descending coronary artery (P < 0.05). Conclusions. In patients with unstable angina and single-vessel coronary artery disease who have been selected for coronary angioplasty, the presence of hyperventilation-induced abnormal coronary vasoconstriction identifies a subgroup at high risk for restenosis