Clopidogrel pre-treatment in stable angina: for all patients >6 h before elective coronary angiography or only for angiographically selected patients a few minutes before PCI? A randomized multicentre trial PRAGUE-8

Abstract

AimsTo compare two different clopidogrel regimens on the outcomes of patients undergoing elective coronary angiography (CAG)±ad hoc percutaneous coronary intervention (PCI).Methods and resultsOpen-trial randomized 1028 patients with stable angina to group A (‘non-selective’—clopidogrel 600 mg >6 h before CAG; n = 513) or group B (‘selective’—clopidogrel 600 mg in the cath-lab after CAG, only in case of PCI; n = 515). Combined primary endpoint was death/periprocedural myocardial infarction (MI)/stroke/re-intervention within 7 days. Secondary endpoints were troponin elevation and bleeding complications. Primary endpoint occurred in 0.8% group A patients vs. 1% group B (P = 0.749; 90% CI for the percentage difference −1.2–0.8). Periprocedural troponin elevation (>3× ULN) was detected in 2.6% group A vs. 3.3% group B (P = 0.475; 90% CI −2.5–1.0). Bleeding complications occurred in 3.5% group A patients vs. 1.4% group B (P = 0.025). After adjustment for covariates and factors that may influence the bleeding risk, patients in group A were shown to have more likely bleeding complications when compared with group B (OR = 3.03; 95% CI 1.14–8.10; P = 0.027).ConclusionHigh (600 mg) loading dose of clopidogrel before elective CAG increased the risk of minor bleeding complications, while the benefit on periprocedural infarction was not significant. Clopidogrel can be given safely in the catheterization laboratory between CAG and PCI in chronic stable angina patients.

Pretreatment with P2Y 12 Inhibitors in Non–ST-Segment–Elevation Acute Coronary Syndrome: An Outdated and Harmful Strategy

“…However, this benefit was driven mainly by periprocedural myocardial infarction, a controversial end point. Of importance, similar trends were observed in elective PCI in that 15% to 40% of NSTE-ACS patients were stabilized [27][28][29] ( Figure 2B). One may argue that the lack of mortality benefit in this patient subset is a concern.…”

2013 Esc Guidelines on the Management of Stable Coronary Artery Disease

“…На основании нескольких рандомизированных исследований и данного мета-анализа (и в отличие от диффузной общепринятой практики), пациенты с СИБС, которым проводят диагностическую коронарную ангиографию с воз-можным проведением ЧКВ по ситуации (реваскуля-ризация в рамках одной и той же процедуры) не должны получать клопидогрел до того, как будет изучена анатомия коронарного русла [386][387][388]. Риск кровотечения при рутинной ДАТ, назначенной перед катетеризацией у пациентов, не нуждающихся в стен-тировании (нет значимой ИБС, либо ИБС, требую-щая проведения КШ), не уравновешивается обнару-живаемой пользой с точки зрения ишемических событий у лиц, проходящих ЧКВ.…”

Pharmacotherapy During Percutaneous Coronary Interventions

“…Similarly, the PRAGUE-8 and ARMYDA-5 PRELOAD trials reported no differences in outcomes when clopidogrel 600 mg was given to patients with stable angina or NSTE-ACS either before (mean of 19 and 6 hours respectively) or immediately after diagnostic coronary angiography, but prior to PCI (49)(50).…”