Clopidogrel pre-treatment is associated with reduced in-hospital mortality in primary percutaneous coronary intervention for acute ST-elevation myocardial infarction

Abstract

AIMS Pre-treatment with clopidogrel results in a reduction of ischaemic events in non-ST-elevation acute coronary syndromes. Data on upstream clopidogrel in the setting of primary percutaneous coronary intervention (PCI) are limited. The aim of this study was to investigate whether clopidogrel loading before arrival at the PCI centre may result in an improved outcome of primary PCI for ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS In a multicentre registry of acute PCI, 5955 patients undergoing primary PCI in Austria between January 2005 and December 2009 were prospectively enrolled. The patients consisted of two groups, a clopidogrel pre-treatment group (n = 1635 patients) receiving clopidogrel before arrival at the PCI centre and a peri-interventional clopidogrel group (n = 4320 patients) receiving clopidogrel at a later stage. Multiple logistic regression analysis including major confounding factors stratified by the participating centres was applied to investigate the effect of pre-treatment with clopidogrel on the in-hospital mortality. Additionally, two subgroups, with or without the use of GP IIb/IIIa antagonist therapy in the catheterization laboratory, were analysed. On univariate analysis, clopidogrel pre-treatment was associated with a reduced in-hospital mortality (3.4 vs. 6.1%, P< 0.01) after primary PCI. On multivariate analysis, clopidogrel pre-treatment remained an independent predictor of in-hospital mortality [odds ratio (OR) = 0.60, 95% confidence interval (CI) 0.35-0.99; P =0.048], especially in patients receiving additional GP IIb/IIIa antagonist therapy in the catheterization laboratory (OR = 0.40, 95% CI 0.19-0.83; P =0.01). CONCLUSION Clopidogrel pre-treatment before arrival at the PCI centre is associated with reduced mortality in a real world setting of primary PCI. These results strongly support the recommendation of clopidogrel treatment 'as soon as possible' in patients with STEMI undergoing pimary PCI.

Perspectives on the 2014 ESC/EACTS Guidelines on Myocardial Revascularization

“…Notably, the administration of P2Y 12 inhibitors before catheterization in ST segment elevation myocardial infarction (STEMI) is recommended, and ideally, they should be administered at the time of the first medical contact. This recommendation is in keeping with American guidelines and is supported by a small randomized study [24], two observational studies [25, 26], and one meta-analysis [20] showing a reduction of death and MACE without increase of bleeding, in STEMI patients pretreated with clopidogrel.…”

Predictors of High On-Treatment Platelet Reactivity Early After Clopidogrel Loading in ST-Elevation Myocardial Infarction

“…Data from registries and a metaanalysis showed that pretreatment with clopidogrel was associated with higher initial patency and improved outcome, including the combined endpoint of death and myocardial infarction at 1 year. [21][22][23][24] In contrast, in the CRUSADE initiative involving 3,785 patients with STEMI undergoing PPCI, the risk of adverse outcomes and bleeding events were similar in the pre-vs. peri-PCI clopidogrel cohorts, with reinfarction occurring more frequently in the pre-PCI group. 25 Of note, in the only so far randomized study, the early use of 600 mg clopidogrel had a similar effect to that of placebo on flow rates, possibly because of the short clopidogrel to angiography time.…”

Current outcome of acute coronary syndromes: data from the Zurich-Acute Coronary Syndrome (Z-ACS)-Registry

“…Indeed, a report published by Stauffer et al, using data from the Acute Myocardial Infarction Swiss-Plus (AMIS Plus) registry, found, as in a similar Austrian study [30], that patients pretreated with combination of clopidogrel and percutaneous coronary intervention (PCI) had significantly lower morbidity and mortality, which may not be the case in settings with limited access to resources [31].…”