Clopidogrel Pre-Treatment Is Associated With Reduced In-Hospital Mortality in Primary Percutaneous Coronary Intervention for Acute ST-Elevation Myocardial Infarction

Study Questions:

What is the clinical benefit of preloading with clopidogrel in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI)?

Methods:

The authors compared the outcome of patients pretreated with clopidogrel (prior to arrival at the PCI center) with those who were not preloaded prior to undergoing primary PCI. All patients were enrolled in the Austrian Acute PCI registry.

Results:

Of the 5,955 patients who underwent primary PCI during the study period, 1,635 patients were pretreated with clopidogrel. Patients pretreated with clopidogrel were less likely to be in cardiogenic shock (8.4% vs. 11.2%) or require cardiopulmonary resuscitation prior to PCI (5.2% vs. 9.6%). Clopidogrel pretreatment was associated with lower in-hospital mortality (3.4 vs. 6.1%, p < 0.01) after primary PCI. After adjusting for baseline differences, clopidogrel pretreatment was an independent predictor of lower in-hospital mortality (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.35-0.99; p = 0.048). This difference was more pronounced in the patients who were treated with platelet glycoprotein IIb/IIIa inhibitors in the catheterization laboratory (OR, 0.40; 95% CI, 0.19-0.83; p = 0.01).

Conclusions:

The authors concluded that clopidogrel pretreatment is associated with a lower mortality among patients undergoing primary PCI for STEMI.

Perspective:

This study suggests that clopidogrel preloading is associated with a dramatic reduction in in-hospital mortality among patients undergoing primary PCI. Clopidogrel preloading was more commonly performed in patients who were less sick, and it is not clear if the findings of this study reflect immigration bias and residual confounding or a true survival benefit of early clopidogrel. There is little downside to early administration of clopidogrel (or prasugrel or ticagrelor) in most patients undergoing primary PCI, and the results of this study support such a strategy, especially in patients who are transferred for primary PCI.

Clinical Topics: Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, SCD/Ventricular Arrhythmias

Keywords: Odds Ratio, Myocardial Infarction, Hospital Mortality, Platelet Aggregation Inhibitors, Shock, Emigration and Immigration, Thiophenes, Cardiopulmonary Resuscitation, Ticlopidine, Piperazines, Angioplasty, Purinergic P2Y Receptor Antagonists, Percutaneous Coronary Intervention, Registries, Catheterization, Confidence Intervals


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