Options and outcomes with different antiplatelet strategies during primary percutaneous coronary intervention

Abstract

The antithrombotic armamentarium for the treatment of acute coronary syndromes has expanded so rapidly over the past decade that this evolution has challenged the pace at which large-scale clinical trials can be completed for new indications and cardiac society guidelines can be updated. For example, there are presently 60 different antiplatelet and anticoagulant combinations for drugs with Class I or II indications for the treatment of ST-segment elevation myocardial infarction (STEMI). Considering clopidogrel in particular, the current European Society of Cardiology (ESC) guidelines1 recommend an oral loading dose of at least 300 mg for patients undergoing primary percutaneous coronary intervention (PCI) (Class I, Level of Evidence C). In the acute phase of STEMI, a clopidogrel maintenance dose of 75 mg daily is recommended (I, A) and, while the optimal duration of clopidogrel has not been determined, therapy for 12 months in all STEMI patients is recommended (IIa, C). Similarly, the current American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend clopidogrel for patients with STEMI regardless of whether they undergo reperfusion with fibrinolytic therapy (I, A).2 These updates are based on the Clopidogrel and Metoprolol in Myocardial Infarction Trial/Second Chinese Cardiac Study (COMMIT/CCS-2) and the Clopidogrel as Adjunctive Reperfusion Therapy (CLARITY)-Thrombolysis in Myocardial Infarction (TIMI) 28 trials, which did not employ PCI as the primary reperfusion strategy.3,4 No prior large-scale trial or registry has demonstrated a mortality-lowering benefit from high-dose clopidogrel among primary PCI patients, though some relevant data are emerging.5,6 Witkowski et al. 7 report their findings among 7193 patients undergoing primary PCI during 2003 and included in a multicentre Polish STEMI registry. In particular, the authors retrospectively analysed data from 38 centres and separated patients according to the periprocedural use of a … *Corresponding author. Tel: +1 859 323 5843, Fax: +1 859 257 3537, Email: moliterno{at}uky.edu