Colchicine in coronary artery and cerebrovascular disease: “Old skin for the new ceremony”

Colchicine is one of the most widely used drugs in the world. While it is most commonly used in the treatment and prevention of gout, it is also widely used to treat other chronic inflammatory diseases, such as familial Mediterranean fever and Behçet's disease. Regarding cardiovascular disease, an established use of colchicine concerns pericarditis, both acute and chronic, and its effectiveness in this context is supported by multiple studies and robust evidence. Regarding coronary artery disease (CAD), colchicine use has been endorsed in both acute and chronic coronary syndromes (CCS), primarily because of two randomized controlled trials: The COLCOT trial for patients with acute coronary syndromes (ACS) and the LoDoCo2 trial for patients with CCS. Considering this robust evidence, CCS 2024 European Society of Cardiology (ESC) Guidelines recommended 0.5 mg daily colchicine in patients with atherosclerotic CAD to reduce the risk of myocardial infarction, stroke and need for revascularization. However, a few months after the publication of 2024 ESC Guidelines on CCS, the "CLEAR" trial demonstrated that among patients who had experienced an acute myocardial infarction, when initiated shortly after the event and continued for a median of 3 years, colchicine did not reduce the incidence of the composite outcome of death from cardiovascular causes, recurrent myocardial infarction, stroke, or unplanned ischemia-driven coronary revascularization. This result casts doubt on the indication for colchicine use in ACS and weakens evidence that had previously led to the routine use of colchicine in clinical cardiology practice. This review aims to shed light on the current and past scientific evidence underlying the use of colchicine in ACS, CCS and cerebrovascular disease, and thus seeks to provide a quick yet effective tool for cardiologists facing the long-standing issue of reducing residual inflammatory risk in patients with coronary atherosclerotic disease.