The Sooner, the Better: Anti-inflammation in Acutemyocardial Infarction

Thomas F. Lüscher

Disclosures

Eur Heart J. 2020;41(42):4100-4102. 

In This Article

Colchicine After Acute Coronary Syndromes?

Should we now use colchicine in the very early phase of ACS as a remedy to reduce MACE? First of all, colchicine is cheap and, particularly at the low dose used in COLCOT, relatively well tolerated. Indeed, in the COLCOT trial, gastrointestinal side effects such as nausea and flatulence were quite rare, with 2.4% vs. 1.2% with placebo. Obviously, as any anti-inflammatory drug, colchicine increases the risk of infection. Pneumonia was rare, but indeed more common, with 0.9% vs. 0.4% with colchicine and placebo, respectively. Should we therefore avoid prescribing colchicine for the elderly who are at risk of pneumonia or provide them with pneumococcal vaccination? Indeed, acute infections may precipitate myocardial infarction, while influenza, tetanus, and pneumococcal vaccinations do not produce a detectable increase in this risk, but may actually be protective.[26] As such, this may be a reasonable precaution in this context.

A second question is whether colchicine would be suitable for all ACS patients or only for those with signs of excessive inflammation? Indeed, not all patients with ACS have signs of inflammation. Typically, out-of-the-blue infarctions are triggered by other stimuli (such as shear stress, pulsatility, spasm, etc.), while in heralded infarction inflammation plays a primary role.[10,27] Unfortunatly, CRP or SAA were not assessed in COLCOT and hence a more personalized use of this drug awaits further studies. Overall, however, the main COLCOT trial and now this important subanalysis open the door for an even more effective treatment of patients with ACS with remaining inflammatory risk.

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