Impact of Final Activated Clotting Time After Transradial Coronary Stenting With Maximal Antiplatelet Therapy Olivier F. Bertrand, MD, PhD*, Josep Rodés-Cabau, MD, Stéphane Rinfret, MD, MSc, Éric Larose, DVM, MD, Rodrigo Bagur, MD, Guy Proulx, MD, Onil Gleeton, MD, Olivier Costerousse, PhD, Robert De Larochellière, MD, and Louis Roy, MD The optimal value of activated clotting time (ACT) during percutaneous coronary inter- vention (PCI) with unfractionated heparin remains controversial. No data are available on the relation between the ACT at the end of the procedure (final ACT) and the clinical outcomes after transradial PCI and maximal antiplatelet therapy. By dividing the final ACT values in tertiles, we analyzed the ischemic and bleeding events in 1,234 consecutive patients with acute coronary syndrome recruited in the EArly Discharge after Transradial Stenting of CoronarY Arteries (EASY) trial. All patients were pretreated with aspirin and clopidogrel. After radial sheath insertion, patients received 70 IU/kg unfractionated hep- arin. Abciximab was given before the first balloon inflation. The median final ACT value was 312 seconds (interquartile range 279 to 344). At 30 days, the rate of major adverse cardiac events, including death, myocardial infarction, and target vessel revascularization, from the lower to upper tertiles was 4%, 4%, and 2%, respectively (p  0.16), and the rate of major bleeding was 2%, 1% and 0.7%, respectively (p  0.20). During the 3 years of follow-up, the incidence of myocardial infarction was less in the tertile with the greatest ACT value (>330 seconds) than in the other 2 tertiles (4%, 8%, and 8%, respectively; p  0.038). Troponin-T and creatine kinase-MB release after PCI indicated that the effect was related to periprocedural myonecrosis protection. After adjustment for baseline and pro- cedural differences, a final ACT of >330 seconds remained associated with a 47% relative reduction in myocardial infarction (odds ratio 0.53, 95% confidence interval 0.29 to 0.93, p  0.024). Death and target vessel revascularization remained similar in all tertiles for <3 years. In conclusion, with the combination of aspirin, clopidogrel pretreatment, and abciximab, a final ACT value of >330 seconds appears protective against peri-PCI myonecrosis, and this benefit was maintained for <3 years. With a transradial approach and maximal antiplatelet therapy, greater ACT values did not correlate with an increased risk of bleeding. © 2009 Elsevier Inc. All rights reserved. (Am J Cardiol 2009;104:1235–1240) No data have yet been reported on the clinical effect of the final activated clotting time (ACT) after transradial percutaneous coronary intervention (PCI) and maximal an- tiplatelet therapy, including aspirin, clopidogrel, abciximab, and unfractionated heparin (UFH). The objective of the present analysis was to evaluate the relation between the final ACT value and acute and late bleeding and ischemic outcomes in patients with acute coronary syndrome re- cruited in the EArly Discharge after Transradial Stenting of CoronarY Arteries (EASY) trial. Methods The details of the EASY trial have been previously described. 1 In brief, patients referred for coronary angiog- raphy and possible PCI were enrolled. Patients were ex- cluded if they had presented with ST-elevation myocardial infarction (MI) within 72 hours or a history of left ventric- ular ejection fraction of 30%. The protocol was approved by Health Canada and the Institut Universitaire de Cardi- ologie et de Pneumologie de Québec ethics review board (Quebec, Quebec, Canada), and the protocol was published on the Clinical Trials Web site (www.clinicaltrials.gov, clinical trial number NCT001169819). All patients provide written informed consent before the procedure. The study was a randomized, controlled, open-label study comparing same-day home discharge and bolus-only of abciximab to overnight hospitalization and bolus fol- lowed by a 12-hour infusion of abciximab after uncompli- cated transradial coronary stenting. 2 In the case of subopti- mal results or clinical complications, patients were excluded from same-day discharge after PCI and received the abcix- imab bolus and infusion. 3 Abciximab was administered as a 0.25-mg/kg bolus before the first balloon angioplasty, and the infusion was given for a total of 12 hours at 0.125 Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, Quebec, Canada. Manuscript received May 13, 2009; revised manuscript received and accepted June 16, 2009. The EASY trial was an investigator-initiated trial supported by unre- stricted grants from Eli Lilly, Indianapolis, Indiana, Bristol-Myers Squibb (New York, New York)/Sanofi-Aventis, Paris, France, Régie Régionale de Québec, Quebec, Canada, and Corporation de l’Institut de Cardiologie de Québec, Montreal, Québec, Canada. Drs. Bertrand, Rinfret, and Larose are research-scholars from the Fonds de la Recherche en Santé du Québec, Montreal, Quebec, Canada. *Corresponding author: Tel: (418) 6568711; fax: (418) 6564544. E-mail address: olivier.bertrand@criucpq.ulaval.ca (O. Bertrand). 0002-9149/09/$ – see front matter © 2009 Elsevier Inc. All rights reserved. www.AJConline.org doi:10.1016/j.amjcard.2009.06.036