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Patients' response to dual antiplatelet therapy (DAPT) is subject to variations and its monitoring allows to individualize this therapy. In this study, we evaluated if a strategy of tailored DAPT after platelet function testing could reduce high on-treatment platelet reactivity (HPR) and improve outcome of patients treated with stent implantation. In 257 patients undergoing percutaneous angioplasty, platelet function was measured by light transmittance aggregometry (LTA) using 10 µM/L adenosine-diphosphate (ADP) and 1 mM arachidonic acid (AA) as agonists. Patients with HPR by ADP (≥70%) were switched to double-dose clopidogrel, ticlopidine, prasugrel or ticagrelor; in patients with HPR by AA (≥20%) acetylsalicylic acid dose was increased if not contraindicated. Platelet function analysis was repeated 48 hours after therapy variation. At 20-month follow-up major adverse cardiovascular events (MACE) and bleedings were assessed. HPR was detected in 97/257 (37.7%) patients: 69/257 (26.8%) had HPR by ADP and 71/257 (27.6%) had HPR by AA. In patients with HPR by ADP or by AA, tailored DAPT determined a significant reduction in residual platelet reactivity. No significant difference in MACE or bleeding occurrence was documented in HPR patients treated with tailored DAPT vs. those without HPR. HPR patients treated with tailored DAPT had significant lower follow-up MACE and deaths vs. 139 HPR patients not switched, even after propensity score analysis. These results suggest that a DAPT tailored on platelet testing can improve antiplatelet response in HPR patients, possibly reducing their thrombotic events to a level similar to non-HPR patients, without increasing the risk of bleeding.

Several studies have evaluated the prognostic impact of atrial fibrillation (AF) in ST-elevation myocardial infarction (STEMI) patients, but scarce data are available on the role of AF in non-ST-elevation acute coronary syndromes (NSTE-ACS). The aim of this study was to investigate long-term outcome of NSTE-ACS patients experiencing an episode of AF during in-hospital course. Of 1,147 NSTE-ACS patients, 54.4% for non-STEMI (NSTEMI) and 45.6% for unstable angina, 65 (5.7%) had an episode of AF. Long-term survival was compared with that of 1,082 NSTE-ACS patients who did not develop AF. Patients who developed AF, with respect to those who did not, were older and more frequently with NSTEMI at admission (69.2 vs. 53.5%, p = 0.013), diabetes, dyslipidemia and history of heart failure. Moreover, patients who developed AF had a significantly higher New York Heart Association class and lower values of glomerular filtration rate. During a median follow-up of 40.7 months, we observed a significantly higher mortality in NSTE-ACS patients who developed AF versus those who did not (42.2 vs. 19.8%, p < 0.001). AF occurrence in NSTE-ACS was a significant predictor of mortality at Cox regression (adjusted HR: 1.85; p = 0.03). After propensity score analysis, only patients with AF duration >6 h showed a significantly higher mortality at Cox regression (p = 0.021). Our results suggest that NSTE-ACS patients who develop AF are characterized by a higher clinical complexity. The occurrence of AF, when longer than 6 h, represents an important negative prognostic factor for long-term survival.

In non-ST-elevation acute coronary syndromes (ACS), an early invasive strategy is recommended for middle/high-risk patients; however, the optimal timing for coronary angiography is still debated. The aim of this study was to evaluate the prognostic implications of the time of angiography in ACS patients treated in accord with an early invasive strategy. We analyzed the relationship between the time of angiography and outcomes at follow-up in 517 ACS patients, of whom 482 were revascularized with percutaneous coronary intervention (PCI) (86.9%) or coronary artery by-pass graft (13.1%). We also evaluated the influence of clinical, biohumoral and angiographic variables on the patients' outcomes at follow-up. Among patients submitted to angiography at different time intervals from both hospital admission and symptom onset, significant differences neither in mortality nor in cardiac ischemic events at follow-up were observed. At univariate analysis, complete versus partial revascularization, longer hospital stay, higher TIMI risk score, diabetes mellitus, higher discharge creatinine and admission anemia were associated with mortality and cardiac ischemic events at follow-up; a lower left ventricular ejection fraction was associated with mortality; higher peak troponin I and previous PCI were associated with cardiac ischemic events at follow-up. At multivariate analysis longer hospital stay, higher discharge creatinine levels, and previous PCI were independent predictors of cardiac ischemic events at follow-up. Our evaluation in ACS patients treated with an early invasive strategy does not support the concept that angiography should be performed as soon as possible after symptom onset or hospital admission. Rather, an unfavorable long-term outcome is influenced principally by the clinical complexity of patients.