title: Impact of prasugrel pretreatment and timing of coronary artery bypass grafting on clinical outcomes of patients with non-ST-segment elevation myocardial infarction: From the A Comparison of Prasugrel at PCI or Time of Diagnosis of Non-ST-Elevation Myocardial Infarction (ACCOAST) study.
abstract: OBJECTIVE
  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.affiliation: Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland. Electronic address: mcdudek@cyfronet.pl.
authors.forename: Dariusz
authors.initials: D
authors.lastname: Dudek
authors.affiliation: Department of Interventional Cardiology, Jagiellonian University Medical College, Krakow, Poland.
authors.forename: Artur
authors.initials: A
authors.lastname: Dziewierz
authors.affiliation: Third Medical Faculty of Charles University and University Hospital Royal Vineyards, Prague, Czech Republic.
authors.forename: Petr
authors.initials: P
authors.lastname: Widimsky
authors.affiliation: Cardiovascular and Neurological Department, Azienda Ospedaliera, Arezzo, Italy.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Bolognese
authors.affiliation: SAMU and Emergency Department, Lille University Hospital, Lille, France.
authors.forename: Patrick
authors.initials: P
authors.lastname: Goldstein
authors.affiliation: Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Hamm
authors.affiliation: Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Jean-Francois
authors.initials: JF
authors.lastname: Tanguay
authors.affiliation: Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA.
authors.forename: LeRoy
authors.initials: L
authors.lastname: LeNarz
authors.affiliation: Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA.
authors.forename: Debra L
authors.initials: DL
authors.lastname: Miller
authors.affiliation: Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA.
authors.forename: Eileen
authors.initials: E
authors.lastname: Brown
authors.affiliation: Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands.
authors.forename: Jurrien
authors.initials: J
authors.lastname: Ten Berg
authors.affiliation: ACTION Study Group, Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtriėre (AP-HP), Université Paris 6, Paris, France.
authors.forename: Gilles
authors.initials: G
authors.lastname: Montalescot
mesh_terms: D000368:Aged; D001026:Coronary Artery Bypass / Q000379:methods*; D004305:Dose-Response Relationship, Drug; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000628:therapy*; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D000068799:Prasugrel Hydrochloride / Q000008:administration & dosage*; D011300:Preoperative Care / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D000068799:Prasugrel Hydrochloride