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September 14, 2005

Clopidogrel for Percutaneous Coronary RevascularizationTime for More Pretreatment, Retreatment, or Both?

Author Affiliations

Author Affiliations: Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington.

JAMA. 2005;294(10):1271-1273. doi:10.1001/jama.294.10.1271

Antiplatelet agents—aspirin, thienopyridines, and glycoprotein IIb/IIIa (GpIIb/IIIa) inhibitors—have become cornerstones in the treatment of ischemic heart disease for patients with acute coronary syndrome (ACS) and for those undergoing percutaneous coronary intervention (PCI). Depending on the clinical scenario and the concomitant anticoagulants used, regimens combining 2 or more of these antiplatelet agents have resulted in fewer ischemic events and sometimes more bleeding events compared with aspirin alone. In patients with ST-segment elevation myocardial infarction (STEMI), aspirin has been shown to safely reduce mortality vs placebo,1 and it therefore serves a foundational role in thrombolytic therapy regimens. The addition of the most potent platelet aggregation inhibitors, GpIIb/IIIa receptor antagonists, to thrombolytic therapy (aspirin, heparin, and a fibrinolytic agent) in STEMI patients has not resulted in lower mortality rates but has reduced reinfarction rates. A meta-analysis of randomized trials testing abciximab (a GpIIb/IIIa inhibitor) among 23 166 STEMI patients receiving thrombolytic therapy reported 30-day mortality rates of 5.8% for both the abciximab and control groups, whereas the respective rates of reinfarction were 2.3% and 3.6% (odds ratio [OR], 0.64; P<.001).2 Offsetting this benefit, however, abciximab was associated with a higher rate of major bleeding complications (5.2% vs 3.1%; OR, 1.77; P<.001).

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