Original title: Association of Clopidogrel Pretreatment with mortality, Cardiovascular events, and Major Bleeding among patients undergoing percutaneous coronary intervention. A systematic review and Mata-analysis. Reference: Anne Bellemain-Appaix, MD et al. for the ACTION group.

The loading of clopidogrel before coronary angioplasty is an accepted practice by most clinical and interventional cardiologists but, nevertheless, it is only based on weak evidence 

Through this meta-analysis the authors attempt to answer the question of whether the use of clopidogrel as a pretreatment to angioplasty, (in any case scenario), has any impact on the development of hard events, (specifically death).

We included a total of 37,814 patients from 15 randomized and observational studies. The result of meta- analysis showed that the use of clopidogrel as a pretreatment to angioplasty does not reduce mortality, (1.54% versus 1.97%, p=0.17), although it was associated with a significant reduction in major cardiac events, (9.83% versus 12.35%; OR 0.77; p< 0.001). 

There was no difference in the rate of major bleeding (3.57% versus 3.08%, OR 1.18, P = 0.18). When analyzing subgroups, clopidogrel loading before angioplasty in patients enrolled in an acute myocardial infarction with ST elevation demonstrated a benefit in mortality, (1.28% versus 2.54%, OR 0.50, P = 0.04) as well as in reducing major cardiac events, (3.56% versus 6.36%, P = 0.003). We also observed reduced major cardiac events in patients with acute coronary syndromes without ST-segment elevation, (13.91% versus 17.19%, P = .002)

Conclusion 

Clopidogrel use in doses above 300 mg prior to coronary angioplasty would not impact on mortality rates although it does help reduce major cardiovascular events.

Editorial Comment:

It is interesting to observe how a common practice is supported by inconsistent evidence. This is reflected in the guidelines (i.e. European guide) that recommend a loading dose of 300 mg 6 hours before elective angioplasty, (or 600 mg 2 hours prior), and 600 mg as soon as possible in primary angioplasty with a class 1 level of recommendation but based on a level of evidence b/c. It seems that this meta-analysis supports the use of clopidogrel pretreatment for high-risk patients, (acute coronary syndromes), but invites us to rethink its use in low-risk patients undergoing scheduled angioplasty. 

Courtesy of María Sol Andrés, MD.
University Hospital,
Fundación Favaloro – Argentina.

Dra. María Sol Andrés para SOLACI.ORG