Dariusz Dudek1, Artur Dziewierz2, Petr Widimsky3, Leonardo Bolognese4, Patrick Goldstein5, Christian Hamm6, Jean-Francois Tanguay7, LeRoy LeNarz8, Debra L Miller8, Eileen Brown8, Jurrien Ten Berg9, Gilles Montalescot10. 1. Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland. Electronic address: mcdudek@cyfronet.pl. 2. Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland. 3. Third Medical Faculty of Charles University and University Hospital Royal Vineyards, Prague, Czech Republic. 4. Cardiovascular and Neurological Department, Azienda Ospedaliera, Arezzo, Italy. 5. SAMU and Emergency Department, Lille University Hospital, Lille, France. 6. Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany. 7. Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada. 8. Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA. 9. Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands. 10. ACTION Study Group, Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtriėre (AP-HP), Université Paris 6, Paris, France.
Abstract
OBJECTIVES: We evaluated impact of timing of coronary artery bypass grafting (CABG) and prasugrel pretreatment in patients with non-ST-segment elevation myocardial infarction undergoing CABG in the ACCOAST study. METHODS: Of 4033 enrolled patients, 314 (7.8%) underwent isolated CABG through 30 days. Primary efficacy end point for this analysis was any cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa inhibitor bailout through 30 days. RESULTS: More CABG versus percutaneous coronary intervention or medically managed patients were men, diabetic, or had peripheral arterial disease. Per randomization, 157 of 314 patients received a 30-mg prasugrel loading dose before CABG, and 157 of 314 received placebo. Patients were stratified by tertile of time from randomization to CABG: <2.98 days (n = 104), ≥2.98 and <6.95 days (n = 106), and ≥6.95 days (n = 104). Primary end point occurred in 12.5%, 4.7%, and 4.8%, respectively (<2.98 days vs other tertiles, hazard ratio [HR] = 2.80; P = .011). Similarly, the rate of all TIMI major bleeding was highest in the lowest tertile (26.0% vs 10.4% and 4.8%; P < .001), but no difference in all-cause death was observed through 30 days (3.9% vs 1.9% and 1.9%; P = .30). Time from randomization to CABG (HR = 0.84 for each day delay), left main disease (HR = 1.76), region of enrollment (Non-Eastern Europe vs Eastern Europe; HR = 3.83), but not prasugrel pretreatment and baseline troponin ≥3× upper limit of normal, were independent predictors of combined 30-day end point of all-cause death/myocardial infarction/stroke/TIMI major bleeding. CONCLUSIONS: In ACCOAST, early (<2.98 days) surgical revascularization carried increased risk of bleeding and ischemic complications without affecting all-cause mortality through 30 days. Baseline troponin and prasugrel pretreatment did not impact ischemic clinical outcomes.
RCT Entities:
OBJECTIVES: We evaluated impact of timing of coronary artery bypass grafting (CABG) and prasugrel pretreatment in patients with non-ST-segment elevation myocardial infarction undergoing CABG in the ACCOAST study. METHODS: Of 4033 enrolled patients, 314 (7.8%) underwent isolated CABG through 30 days. Primary efficacy end point for this analysis was any cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa inhibitor bailout through 30 days. RESULTS: More CABG versus percutaneous coronary intervention or medically managed patients were men, diabetic, or had peripheral arterial disease. Per randomization, 157 of 314 patients received a 30-mg prasugrel loading dose before CABG, and 157 of 314 received placebo. Patients were stratified by tertile of time from randomization to CABG: <2.98 days (n = 104), ≥2.98 and <6.95 days (n = 106), and ≥6.95 days (n = 104). Primary end point occurred in 12.5%, 4.7%, and 4.8%, respectively (<2.98 days vs other tertiles, hazard ratio [HR] = 2.80; P = .011). Similarly, the rate of all TIMI major bleeding was highest in the lowest tertile (26.0% vs 10.4% and 4.8%; P < .001), but no difference in all-cause death was observed through 30 days (3.9% vs 1.9% and 1.9%; P = .30). Time from randomization to CABG (HR = 0.84 for each day delay), left main disease (HR = 1.76), region of enrollment (Non-Eastern Europe vs Eastern Europe; HR = 3.83), but not prasugrel pretreatment and baseline troponin ≥3× upper limit of normal, were independent predictors of combined 30-day end point of all-cause death/myocardial infarction/stroke/TIMI major bleeding. CONCLUSIONS: In ACCOAST, early (<2.98 days) surgical revascularization carried increased risk of bleeding and ischemic complications without affecting all-cause mortality through 30 days. Baseline troponin and prasugrel pretreatment did not impact ischemic clinical outcomes.
Authors: Jared P Beller; William Z Chancellor; J Hunter Mehaffey; Robert B Hawkins; Elizabeth D Krebs; Alan M Speir; Mohammed A Quader; Leora T Yarboro; Gorav Ailawadi; Nicholas R Teman Journal: Eur J Cardiothorac Surg Date: 2020-06-01 Impact factor: 4.191
Authors: Luke P Dawson; David Chen; Misha Dagan; Jason Bloom; Andrew Taylor; Stephen J Duffy; James Shaw; Jeffrey Lefkovits; Dion Stub Journal: JAMA Netw Open Date: 2021-11-01