Optimal Platelet Inhibition for PCI in ACS: Pretreatment, In-laboratory, Both or Neither

The results of recent trials suggest that an aggressive antiplatelet regimen that includes a glycoprotein (GP) IIb/IIIa antagonist, in conjunction with an early revascularization strategy, may be the optimal treatment plan for patients presenting with a non-ST-elevation acute coronary syndrome (ACS). However, whether all patients presenting to the emergency room with a suspected ACS really benefit from the addition of a GP IIb/IIIa receptor inhibitor, and in those who do, the optimal time to start therapy has not yet been clearly identified. Patients with objective evidence of ischemia, especially elevated myocardial enzymes, as well as patients on chronic aspirin therapy at the time of their ACS, appear to derive the greatest benefit from the addition of a GP IIb/IIIa antagonist. Trial results strongly support the use of a GP IIb/IIIa inhibitor at the time of a percutaneous coronary intervention in this patient population, but starting therapy prior to the procedure is best supported by the data in those patients who have refractory ischemia despite good medical therapy, or patients who will be medically stabilized for greater than 24 hours.