Effects of aspirin dose on ischaemic events and bleeding after percutaneous coronary intervention: insights from the PCI-CURE study

In the setting of percutaneous coronary intervention (PCI), due to a paucity of data, the optimal dose of aspirin isuncertain. We evaluated the safety of different doses of aspirin after PCI.Methods and results In the PCI-CURE study, 2658 patients with acute coronary syndromes undergoing PCI were stratified into three aspirin dose groups 200 mg (high, n » 1064), 101–199 mg (moderate, n » 538), and 100 mg (low, n » 1056). For efficacy, the moderate- (7.4%) and high-dose groups (8.6%) had similar rates of cardiovascular death, myocardialinfarction, or stroke compared with the low-dose group (7.1%). For safety, major bleeding was increased with highdose aspirin [3.9, 1.5, and 1.9% in the high-, moderate-, and low-dose groups; hazard ratio (HR) of high vs. low dose 2.05 (95% CI 1.20–3.50, P » 0.009]. The net adverse clinical events (death, MI, stroke, major bleeding) favoured low-over high-dose aspirin (8.4 vs. 11.0%, HR 1.31, 95% CI 1.00–1.73 P » 0.056). Conclusion In this large observational analysis of patients undergoing PCI, low-dose aspirin appeared to be as effective as higherdoses in preventing ischaemic events but was also associated with a lower rate of major bleeding and an improved net efficacy to safety balance.

Early versus delayed invasive intervention in acute coronary syndromes

Earlier trials have shown that a routine invasive strategy improves outcomes in patients with acute coronary syndromes without ST-segment elevation. However, the optimal timing of such intervention remains uncertain.Methods We randomly assigned 3031 patients with acute coronary syndromes to undergo either routine early intervention (coronary angiography ¡Ü24 hours after randomization)or delayed intervention (coronary angiography ¡Ý36 hours after randomization). The primary outcome was a composite of death, myocardial infarction, or stroke at 6 months. A prespecified secondary outcome was death, myocardial infarction, orrefractory ischemia at 6 months.Results Coronary angiography was performed in 97.6% of patients in the early-intervention group (median time, 14 hours) and in 95.7% of patients in the delayed-intervention group (median time, 50 hours). At 6 months, the primary outcome occurred in 9.6%of patients in the early-intervention group, as compared with 11.3% in the delayedintervention group (hazard ratio in the early-intervention group, 0.85; 95% confidence interval [CI], 0.68 to 1.06; P = 0.15). There was a relative reduction of 28% in the secondary outcome of death, myocardial infarction, or refractory ischemia in the early-intervention group (9.5%), as compared with the delayed-intervention group(12.9%) (hazard ratio, 0.72; 95% CI, 0.58 to 0.89; P = 0.003). Prespecified analyses showed that early intervention improved the primary outcome in the third of patients who were at highest risk (hazard ratio, 0.65; 95% CI, 0.48 to 0.89) but not in the two thirds at low-to-intermediate risk (hazard ratio, 1.12; 95% CI, 0.81 to 1.56; P = 0.01 for heterogeneity)...