In ACCOAST, 4,033 patients with NTSE-ACS and an elevated troponin level were randomly assigned to receive 30 mg prasugrel or placebo before angiography. After a median of 4.3 h, prasugrel (30 mg in patients pretreated with prasugrel and 60 mg in controls) was administered at the time of PCI in patients confirmed to have an indication for the intervention (68.7%). At day 7, first occurrence of cardiovascular death, myocardial infarction, stroke, urgent revascularization, or glycoprotein IIb/IIIa bailout did not significantly differ between the two groups (10.0% with pretreatment vs 9.8% in controls; P = 0.81). However, TIMI major bleeding occurred significantly more often in the patients pretreated with prasugrel (2.6% vs 1.4%; P = 0.006). “Our findings suggest use of prasugrel should be considered only after the coronary anatomy has been defined,” says ACCOAST investigator Gilles Montalescot.