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J Thorac Cardiovasc Surg 2009;138:807-810
© 2009 The American Association for Thoracic Surgery

Expert Commentary

Antiplatelet agents used for early intervention in acute coronary syndrome: Myocardial salvage versus bleeding complications

^a Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
^b Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass

Received for publication January 6, 2009; revisions received March 26, 2009; accepted for publication April 11, 2009.

^_* Address for reprints: Sary Aranki, MD, Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. (Email: saranki@partners.org).

The first 300 words of the full text of this article appear below.

	Introduction

 
Acute coronary syndrome (ACS) is a costly health care issue worldwide.¹ Numerous well-conducted clinical trials have demonstrated that early intervention is associated with the greatest long-term survival, better myocardial preservation, and improved quality of life. Consequently, inpatient cardiovascular procedures in the United States have increased over 4-fold since 1979.¹ Notably, the use of antiplatelet therapies has increased well beyond this number and has affected the management of the one-quarter million patients who undergo cardiac surgery each year. The use of antithrombotic agents carries a risk of minor and major bleeding, notably when patients undergo coronary artery bypass grafting (CABG) in the early phase of ACS, the time at which antithrombotic use is greatest and most effective. Concerns over excess bleeding in patients undergoing CABG may lead to withholding antiplatelet agents, perhaps sacrificing early benefit for some patients. The use of blood products, notably platelet transfusions, to treat bleeding has short- and long-term risks that have not yet been balanced against the risks of decreased myocardial survival associated with nonuse of antiplatelet therapy. A better understanding of the risks and benefits associated with early antiplatelet therapy is necessary to improve the outcomes of all patients with ACS, including those who undergo CABG.

	Value of Early Intervention in ACS

 
Numerous clinical trials conducted over 3 decades have rigorously evaluated management strategies for ACS. These studies have shown that early intervention combined with appropriate antiplatelet agent use results in significantly improved outcomes. The findings of these trials have been used to generate the well-stated and widely used American College of Cardiology/American Heart Association (ACC/AHA) clinical guidelines for ACS management.^2,3

Results of trials such as FRISC-II (Fast Revascularization during Instability in Coronary artery disease-II),⁴ ISAR–COOL (Intracoronary Stenting with Antithrombotic Regimen COOLing off),⁵ and ACUITY (Acute Catheterization and Urgent Intervention Triage strategY)⁶ exemplify the value of antiplatelet drugs in early ACS . . . [Full Text of this Article]

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