Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial: study design and rationale.
BACKGROUND
Patients with acute coronary syndromes (ACS; unstable angina and non-ST-segment elevation myocardial infarction) are at significant risk for death and myocardial infarction. Early angiography followed by revascularization is considered the treatment of choice for moderate- to high-risk patients with ACS. However, despite the integration of newer therapies including stents, glycoprotein IIb/IIIa inhibitors, and thienopyridines, the rate of adverse ischemic events still remains unacceptably high, and the intensive pharmacologic regimens used to stabilize the disrupted atherosclerotic plaque and support angioplasty and surgical revascularization procedures elicit a high rate of bleeding complications. Pilot trials suggest that the thrombin-specific anticoagulant bivalirudin may improve clinical outcomes in ACS.


METHODS
In the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial, 13,800 patients with moderate- to high-risk ACS are being prospectively randomly assigned at up to 600 centers to unfractionated heparin or enoxaparin + IIb/IIIa inhibition, versus bivalirudin + IIb/IIIa inhibition, versus bivalirudin + provisional IIb/IIIa inhibition. All patients undergo cardiac catheterization within 72 hours, followed by percutaneous or surgical revascularization when appropriate. In a second random assignment, patients assigned to receive IIb/IIIa inhibitors are subrandomized to upstream drug initiation, versus IIb/IIIa inhibitor administration during angioplasty only. The primary study end point is the composite of death, myocardial infarction, unplanned revascularization for ischemia, and major bleeding at 30 days. Clinical follow-up will continue for 1 year.


CONCLUSIONS
The ACUITY trial is the largest study yet performed in patients with ACS undergoing an invasive strategy. In addition to evaluating the utility of bivalirudin in ACS, this study will also provide important guidance regarding the necessity for and timing of IIb/IIIa inhibitor administration.
Stone
Gregg W
GW
Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY 10022, USA. gstone@crf.org
Bertrand
Michel
M
Colombo
Antonio
A
Dangas
George
G
Farkouh
Michael E
ME
Feit
Frederick
F
Lansky
Alexandra J
AJ
Lincoff
A Michael
AM
Mehran
Roxana
R
Moses
Jeffrey W
JW
Ohman
Magnus
M
White
Harvey D
HD
D000789:Angina, Unstable / Q000188:drug therapy* / Q000628:therapy; D015906:Angioplasty, Balloon, Coronary; D000925:Anticoagulants / Q000627:therapeutic use*; D000991:Antithrombins / Q000627:therapeutic use; D006328:Cardiac Catheterization; D003131:Combined Modality Therapy; D001026:Coronary Artery Bypass; D017984:Enoxaparin / Q000627:therapeutic use; D006493:Heparin / Q000627:therapeutic use; D006629:Hirudins / Q000031:analogs & derivatives*; D006801:Humans; D015337:Multicenter Studies as Topic; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000628:therapy; D010446:Peptide Fragments / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*; D011446:Prospective Studies; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D011994:Recombinant Proteins / Q000627:therapeutic use*; D012107:Research Design
D000925:Anticoagulants; D000991:Antithrombins; D017984:Enoxaparin; D006629:Hirudins; D010446:Peptide Fragments; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D011994:Recombinant Proteins; D006493:Heparin; C074619:bivalirudin