CREDO

2002, Elective PCI

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)

Comments

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

CURE

2001

Trial of Clopidogrel vs Aspirin in NSTEMI pts - Pretreatment

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

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?

PCI-CURE

Trial of Clopidogrel vs Aspirin in NSTEMI pts undergoing PCI

Methods

Pretreatment, median 6 d

Primary Endpoint:

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

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)

CLARITY

2005, STEMI

Clopidogrel vs placebo to pts with STEMI treated with fibrinolytics

Results

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

1. Death
2. Recurrent myocardial infarction before angiography

Comments

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

HORIZONS-AMI

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

Clopidogrel 600 mg vs 300 mg, nonrandomized

Results

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

Comments

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

CURRENT-OASIS 7

2010, ACS

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

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

Comments

1. CABG 7.5%
2. Cath within 72 h

TRITON-TIMI 38

2007, ACS, Prasugrel

Coronary anatomy had to be known before randomization

Results

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

Comments

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

Results

Pretreatment with Ticagrelor reduced both CV complications AND death cf Clopidogrel

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

ACCOAST

2013, NSTEMI, Prasugrel

Results

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

Comments

More bleeding with pretreatment

PLATO

2009, Ticagrelor, ACS (included STEMI pts)

ATLANTIC

2014, STEMI, Ticagrelor in ambulance vs cath lab

Results

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

SUMMARY

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

What do the guidelines say?

2013 AHA/ACC STEMI guidelines

Section on

Adjunctive antithrombotic Rx For Primary PCI