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  • CREDO

    2002, Elective PCI

  • CURE

    2001

    Trial of Clopidogrel vs Aspirin in NSTEMI pts - Pretreatment

  • PCI-CURE

    Trial of Clopidogrel vs Aspirin in NSTEMI pts undergoing PCI

  • CLARITY

    2005, STEMI

    Clopidogrel vs placebo to pts with STEMI treated with fibrinolytics

  • HORIZONS-AMI

    2009, STEMI, Bivalirudin vs IV UFH + GP IIb/IIIa

    Clopidogrel 600 mg vs 300 mg, nonrandomized

  • CURRENT-OASIS 7

    2010, ACS

    Bivalirudin, 600 mg vs 300 mg Clopidogrel loading, Double dose vs regular dose Clopidogrel

  • TRITON-TIMI 38

    2007, ACS, Prasugrel

    Coronary anatomy had to be known before randomization

  • Results

    Pretreatment with Ticagrelor reduced both CV complications AND death cf Clopidogrel

  • ACCOAST

    2013, NSTEMI, Prasugrel

  • PLATO

    2009, Ticagrelor, ACS (included STEMI pts)

  • ATLANTIC

    2014, STEMI, Ticagrelor in ambulance vs cath lab

  • SUMMARY

  • 2013 AHA/ACC STEMI guidelines

  • Results

    1. Clopidogrel pretreatment did not significantly reduce the combined risk of death, MI, or urgent target vessel revascularization at 28 days (P =.23)
    2. Patients who received clopidogrel at least 6 hours before PCI had a 38.6% reduction in the risk events which was borderline statistically significant (p=0.051)
  • Results

    In Rx group:

    1. Less Cardiac death/Nonfatal myocardial infarction, or stroke in Rx group
    2. More bleeding but not more life-threatening bleeding
  • Methods

    Pretreatment, median 6 d

    Primary Endpoint:

    Composite of cardiovascular death, myocardial infarction, or urgent target-vessel revascularisation within 30 days of PCI

  • Results

    Treatment group had lower incidence of 1. Occluded infarct-related artery

    1. Death
    2. Recurrent myocardial infarction before angiography
  • Results

    1. 600-mg vs 300-mg clopidogrel loading dose group had lower 30-day mortality, reinfarction and stent thrombosis w/o more bleeding
  • Results

    1. 600 mg loading dose Clopidogrel preferable t0 300 mg in PCI pts
    2. 150 mg Clopidogrel not better than 75 mg
    3. 300 mg loading dose of ASA, after which 325 mg not superior to 75mg - 100 mg
  • Results

    1. Composite endpoint lower in Rx group
    2. No difference in death rate
  • Comments

    1. Benefit attenuated in N. America
      (p = 0.045 vs < 0.001 for the overall trial)
    2. Because Clopidogrel pretreatment was the “standard”, this trial did not study no pretreatment
    3. CABG rate 10.2%, of whom 2/3 underwent CABG within 7 d
  • Results

    Pretreatment with Prasugrel did not improve outcomes compared with giving the med in the cath lab.

  • Results

    Prehospital administration of ticagrelor in patients with acute STEMI was safe but did not improve pre-PCI coronary reperfusion

  • 1. Clopidogrel pretreatment b/4 PCI is helpful

    2. Clopidogrel needs to be given >/ = 6 hours before cath/PCI

    3. Evidence of its pretreatment efficacy is therefore good for NSTEMI, but rather soft for STEMI

    4. No mortality benefit for Clopidogrel cf Ticagrelor

    5. Our patient population is likely closer to that of CURE population than to that of PLATO

    6. No standard on when should CABG be performed after ACS - but it does not have to be within a few days nor on the same admission

  • Comments

    1. Death 0 (Clopidogrel group) vs 4 (Placebo group)
  • Comments

    1. 12,000 pts enrolled
    2. 2800 had PCI
    3. 2000 had CABG, median 26 d after (12 - 70,5 d)
      In hospital CABG 12 d (8 - 19, 8 - 13)
    4. No difference in mortality
    5. Mechanism of stroke reduction?
  • Results

    4·5% patients in the clopidogrel group had the primary endpoint, compared with 6·4% in the placebo group (relative risk 0·70 [95% CI 0·50–0·97], p=0·03)

  • Comments

    1. No difference in death
    2. Cath was delayed for 48 h
    3. Heparin dosing was carefully done
    4. 6% CABG rate
  • Comments

    1. Non-randomized, observational.
    2. Author himself says it needs to be confirmed by randomized trials
    3. No placebo arm
  • Comments

    1. CABG 7.5%
    2. Cath within 72 h
  • Comments

    Because coronary anatomy had to be known before randomization, CABG rate was the lowest of all trials - 4%

  • Comments

    More bleeding with pretreatment

  • Comments

    What do the guidelines say?

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Death 0 (Clopidogrel group) vs 4 (Placebo group)"},{"_id":"5abd43532fe3ed8522000057","treeId":"5abd33a72fe3ed8522000051","seq":3327827,"position":0.5,"parentId":null,"content":"###CURE\n\n2001\n\nTrial of Clopidogrel vs Aspirin in NSTEMI pts - Pretreatment\n\n"},{"_id":"5abd5c932fe3ed852200005b","treeId":"5abd33a72fe3ed8522000051","seq":3345371,"position":3,"parentId":"5abd43532fe3ed8522000057","content":"####Results\n\nIn Rx group:\n\n1. Less Cardiac death/Nonfatal myocardial infarction, or stroke in Rx group\n2. More bleeding but not more life-threatening bleeding\n"},{"_id":"5abd6e712fe3ed852200005d","treeId":"5abd33a72fe3ed8522000051","seq":3328018,"position":1,"parentId":"5abd5c932fe3ed852200005b","content":"####Comments\n\n1. 12,000 pts enrolled\n2. 2800 had PCI\n3. 2000 had CABG, median 26 d after (12 - 70,5 d)\nIn hospital CABG 12 d (8 - 19, 8 - 13)\n4. No difference in mortality\n5. Mechanism of stroke reduction?"},{"_id":"5abd33be2fe3ed8522000053","treeId":"5abd33a72fe3ed8522000051","seq":3327832,"position":0.6875,"parentId":null,"content":"###PCI-CURE\n\nTrial of Clopidogrel vs Aspirin in NSTEMI pts undergoing PCI","deleted":false},{"_id":"5abd3c4e2fe3ed8522000055","treeId":"5abd33a72fe3ed8522000051","seq":3327975,"position":1,"parentId":"5abd33be2fe3ed8522000053","content":"####Methods\n\nPretreatment, median 6 d\n\nPrimary Endpoint:\n\nComposite of cardiovascular death, myocardial infarction, or urgent target-vessel revascularisation within 30 days of PCI"},{"_id":"5abd3e6b2fe3ed8522000056","treeId":"5abd33a72fe3ed8522000051","seq":3327997,"position":1,"parentId":"5abd3c4e2fe3ed8522000055","content":"####Results\n\n4·5% patients in the clopidogrel group had the primary endpoint, compared with 6·4% in the placebo group (relative risk 0·70 [95% CI 0·50–0·97], p=0·03)"},{"_id":"5abdb22c2fe3ed8522000061","treeId":"5abd33a72fe3ed8522000051","seq":3327837,"position":0.875,"parentId":null,"content":"###CLARITY\n\n2005, STEMI\n\nClopidogrel vs placebo to pts with STEMI treated with fibrinolytics "},{"_id":"5abdbbfa2fe3ed8522000062","treeId":"5abd33a72fe3ed8522000051","seq":3328045,"position":1,"parentId":"5abdb22c2fe3ed8522000061","content":"###Results\n\nTreatment group had lower incidence of 1. Occluded infarct-related artery \n2. Death \n3. Recurrent myocardial infarction before angiography\n\n"},{"_id":"5abdc1ce2fe3ed8522000063","treeId":"5abd33a72fe3ed8522000051","seq":3328055,"position":1,"parentId":"5abdbbfa2fe3ed8522000062","content":"####Comments\n\n1. No difference in death\n2. Cath was delayed for 48 h\n3. Heparin dosing was carefully done\n4. 6% CABG rate"},{"_id":"5abe8df72fe3ed85220000e2","treeId":"5abd33a72fe3ed8522000051","seq":3345407,"position":0.90625,"parentId":null,"content":"###HORIZONS-AMI\n\n\n2009, STEMI, Bivalirudin vs IV UFH + GP IIb/IIIa\n\nClopidogrel 600 mg vs 300 mg, nonrandomized\n\n"},{"_id":"5abea62a2fe3ed85220000e3","treeId":"5abd33a72fe3ed8522000051","seq":3328084,"position":1,"parentId":"5abe8df72fe3ed85220000e2","content":"####Results\n\n1. 600-mg vs 300-mg clopidogrel loading dose group had lower 30-day mortality, reinfarction and stent thrombosis w/o more bleeding"},{"_id":"5abea9842fe3ed85220000e4","treeId":"5abd33a72fe3ed8522000051","seq":3345405,"position":1,"parentId":"5abea62a2fe3ed85220000e3","content":"####Comments\n\n1. Non-randomized, observational.\n2. Author himself says it needs to be confirmed by randomized trials\n3. No placebo arm"},{"_id":"5abe017f2fe3ed8522000067","treeId":"5abd33a72fe3ed8522000051","seq":3328698,"position":0.9375,"parentId":null,"content":"###CURRENT-OASIS 7\n\n2010, ACS\n\nBivalirudin, 600 mg vs 300 mg Clopidogrel loading, Double dose vs regular dose Clopidogrel"},{"_id":"5abe03742fe3ed8522000068","treeId":"5abd33a72fe3ed8522000051","seq":3345414,"position":1,"parentId":"5abe017f2fe3ed8522000067","content":"####Results\n\n1. 600 mg loading dose Clopidogrel preferable t0 300 mg **in PCI pts**\n2. 150 mg Clopidogrel not better than 75 mg\n2. 300 mg loading dose of ASA, after which 325 mg not superior to 75mg - 100 mg"},{"_id":"5abe06122fe3ed8522000069","treeId":"5abd33a72fe3ed8522000051","seq":3328182,"position":1,"parentId":"5abe03742fe3ed8522000068","content":"####Comments\n\n1. CABG 7.5%\n2. Cath within ***72 h***"},{"_id":"5abe0ae62fe3ed852200006a","treeId":"5abd33a72fe3ed8522000051","seq":3327853,"position":0.96875,"parentId":null,"content":"###TRITON-TIMI 38\n\n2007, ACS, Prasugrel\n\n**Coronary anatomy had to be known** before randomization"},{"_id":"5abe193c2fe3ed852200006b","treeId":"5abd33a72fe3ed8522000051","seq":3328437,"position":1,"parentId":"5abe0ae62fe3ed852200006a","content":"####Results\n\n1. Composite endpoint lower in Rx group\n2. No difference in death rate"},{"_id":"5abe1ece2fe3ed852200006c","treeId":"5abd33a72fe3ed8522000051","seq":3340386,"position":1,"parentId":"5abe193c2fe3ed852200006b","content":"####Comments\n\nBecause coronary anatomy had to be known before randomization, CABG rate was the lowest of all trials - 4%"},{"_id":"5abe4faa2fe3ed8522000070","treeId":"5abd33a72fe3ed8522000051","seq":5191989,"position":0.9765625,"parentId":null,"content":"####Results\n\nPretreatment with Ticagrelor reduced both CV complications AND death cf Clopidogrel"},{"_id":"5abe54dc2fe3ed8522000071","treeId":"5abd33a72fe3ed8522000051","seq":3340385,"position":1,"parentId":"5abe4faa2fe3ed8522000070","content":"####Comments\n\n1. Benefit attenuated in N. America \n(p = 0.045 vs < 0.001 for the overall trial)\n2. Because Clopidogrel pretreatment was the \"standard\", this trial did not study no pretreatment\n3. CABG rate 10.2%, of whom 2/3 underwent CABG within 7 d"},{"_id":"5ac35eab5d596a768100002a","treeId":"5abd33a72fe3ed8522000051","seq":3340401,"position":2,"parentId":"5abe4faa2fe3ed8522000070","content":""},{"_id":"5abe30112fe3ed852200006d","treeId":"5abd33a72fe3ed8522000051","seq":3327855,"position":0.984375,"parentId":null,"content":"###ACCOAST\n\n2013, NSTEMI, Prasugrel "},{"_id":"5abe377a2fe3ed852200006e","treeId":"5abd33a72fe3ed8522000051","seq":3328428,"position":1,"parentId":"5abe30112fe3ed852200006d","content":"####Results\n\nPretreatment with Prasugrel did not improve outcomes compared with giving the med in the cath lab. "},{"_id":"5abe720b2fe3ed8522000074","treeId":"5abd33a72fe3ed8522000051","seq":3328292,"position":1,"parentId":"5abe377a2fe3ed852200006e","content":"####Comments\n\nMore bleeding with pretreatment"},{"_id":"5abe3eb52fe3ed852200006f","treeId":"5abd33a72fe3ed8522000051","seq":3327876,"position":0.9921875,"parentId":null,"content":"###PLATO\n\n2009, Ticagrelor, ACS (included STEMI pts)"},{"_id":"5abe5d162fe3ed8522000072","treeId":"5abd33a72fe3ed8522000051","seq":3327872,"position":0.99609375,"parentId":null,"content":"###ATLANTIC\n\n2014, STEMI, Ticagrelor in ambulance vs cath lab"},{"_id":"5abe6da12fe3ed8522000073","treeId":"5abd33a72fe3ed8522000051","seq":3327108,"position":1,"parentId":"5abe5d162fe3ed8522000072","content":"**Results**\n\nPrehospital administration of ticagrelor in patients with acute STEMI was safe but did not improve pre-PCI coronary reperfusion"},{"_id":"5abf1bf46f9ffcc938000032","treeId":"5abd33a72fe3ed8522000051","seq":3327882,"position":1.498046875,"parentId":null,"content":"###SUMMARY"},{"_id":"5abf1c536f9ffcc938000033","treeId":"5abd33a72fe3ed8522000051","seq":3345577,"position":1,"parentId":"5abf1bf46f9ffcc938000032","content":"####1. Clopidogrel pretreatment b/4 PCI is helpful\n####2. Clopidogrel needs to be given >/ = 6 hours before cath/PCI\n####3. Evidence of its pretreatment efficacy is therefore good for NSTEMI, but rather soft for STEMI\n####4. No mortality benefit for Clopidogrel cf Ticagrelor\n####5. Our patient population is likely closer to that of CURE population than to that of PLATO\n####6. No standard on when should CABG be performed after ACS - but it does not have to be within a few days nor on the same admission"},{"_id":"5abf228a6f9ffcc938000034","treeId":"5abd33a72fe3ed8522000051","seq":3328311,"position":1,"parentId":"5abf1c536f9ffcc938000033","content":"####Comments\n\nWhat do the guidelines say?"},{"_id":"5abeda0e54b23397fa000025","treeId":"5abd33a72fe3ed8522000051","seq":3327888,"position":2,"parentId":null,"content":"###2013 AHA/ACC STEMI guidelines\n\n\n"},{"_id":"5abedba354b23397fa000026","treeId":"5abd33a72fe3ed8522000051","seq":3345391,"position":1,"parentId":"5abeda0e54b23397fa000025","content":"###Section on \n\n###[Adjunctive antithrombotic Rx For Primary PCI](http://circ.ahajournals.org/content/127/4/529/T5.expansion.html)\n\n","deleted":false}],"tree":{"_id":"5abd33a72fe3ed8522000051","name":"Trials of antiplatelet agents in ACS","publicUrl":"5abd33a72fe3ed8522000051"}}