This study is part of the RHU INNOV-CKD, winner of the 2019 call for projects. Its aim is to develop two biomarker assays to assess the thrombotic and haemorrhagic risks in patients with stage 3A or more severe chronic kidney disease (CKD) treated with percutaneous coronary intervention (PCI) and antiplatelet therapy following an acute coronary syndrome (ACS). We believe that these tests will help to adapt antiplatelet therapy on an individual basis (in terms of intensity and duration of treatment) and thus reduce the risk of thrombotic and haemorrhagic events in this particularly fragile population. The first biomarker corresponds to an intra-platelet molecule, Rap1b in its active form (known as aRap1b). The second is the pro-antithrombotic balance of circulating endothelial microvesicles (patEMV), which reflects endothelial dysfunction. An automated method for measuring these biomarkers will be developed in partnership with the D.Stago and BioCytex industries during the course of the project.

Inclusion Criteria:

• Man or woman ≥18 years old and <90

• If the subject is a woman, she must be on contraception or menopausal.

• Non-ST-segment elevation ACS defined by the presence of at least 2 of the following criteria: (1) symptoms of myocardial ischemia, (2) electrocardiographic ST-segment abnormalities (depression or transient elevation of at least 0.1 mV) or T-wave inversion in at least in 2 contiguous leads, or (3) an elevated cardiac troponin value (above the upper limit of normal) 56 or ST segment elevation ACS scheduled for primary PCI defined 57 as a history of chest discomfort or ischemic symptoms of >20 minutes duration at rest ≤14 days prior to entry into the study with one of the following present on at least one ECG:

  1. ST-segment elevation ≥1 mm in two or more contiguous ECG leads
  2. New or presumably new left bundle branch block (LBBB).
  3. ST-segment depression ≥1 mm in two anterior precordial leads (V1 through V4) with clinical history and evidence suggestive of true posterior infarction

• Subject intended for an invasive strategy if NSTE-ACS or primary PCI if STE-ACS according to guidelines (appendix X)

• Subject with CKD stage 3A or higher (estimated glomerular filtration rate (eGFR) ≤ 60 ml/min/1.73 m2 according to the CKD-EPI formula

• Because of the documented biological variability of eGRF levels, patients with a eGRF < 78 ml/min/1.73 m2 can be included in this study, based on previous blood test results and on the investigator's decision. The DFG level of 78 ml/min/1.73 m2 correspond to an increase of 30 % of a DFG of 60 ml/min/1.73 m2. Indeed, the literature estimated a DFG levels variability of 30 % 58-61.

• Must be enrolled at a cardiac catheterization laboratory hospital or at a hospital/ambulance service affiliated with a cardiac catheterization laboratory hospital.

• Subject affiliated to or beneficiary of a social security system.

• Subject having signed written informed consent.

Exclusion Criteria:

• - Minors, pregnant or breast-feeding women;
• Subject under chronic anticoagulant
• Subject with thrombolytic therapy during the preceding 24 hours;
• Subject with bleeding diathesis;
• Subject not agreeing to participate.
• Subject with contraindication to clopidogrel, ticagrelor or to another anti platelet agent.
• Severe hepatic failure
• Ischemic Stroke within one month or a history of hemorrhagic stroke
• Platelet count<100 000
• Major surgery or trauma within 10 days
• Life expectancy <1 year
• Known significant bleeding risk according to the physician judgment
• Adults subject to a legal protection measure or unable to express their consent (persons under guardianship, curatorship or safeguard of justice)
• Persons deprived of their rights of liberty by judicial or administrative decision (persons in a situation of social fragility)
• Progressive cancer
• Systemic autoimmune disease
• Chronic viral or bacterial infections
• Diabetes requiring insulin therapy
• Constitutional haemorrhagic syndrome
• Organ transplantation