Ramez Nairooz1, Marco Valgimigli2, Yogita Rochlani3, Naga Venkata Pothineni4, Sameer Raina4, Partha Sardar5, Debabrata Mukherjee6, Srihari S Naidu7, David M Shavelle8. 1. Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA. Electronic address: ramez.nairooz@gmail.com. 2. Division of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, Netherlands. 3. Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA. 4. Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA. 5. Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, USA. 6. Department of Cardiology, Texas Tech University Health Sciences Center, El Paso, TX, USA. 7. Division of Cardiology, Winthrop University Hospital, Mineola, NY, USA. 8. Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA, USA.
Abstract
BACKGROUND: It is unknown whether pretreatment with clopidogrel in acute coronary syndrome (ACS) managed invasively, is superior to a strategy of administering clopidogrel in the cardiac catheterization laboratory at the time of percutaneous coronary intervention (PCI). Current practice guidelines do not endorse one strategy over the other. METHODS: A comprehensive literature search was done to identify all relevant studies comparing pretreatment with clopidogrel to administration in the cardiac catheterization laboratory at the time of PCI (no pretreatment). A meta-analysis using a random effects model was used to calculate outcomes of interest. RESULTS: Our search identified 16 studies including 61,517 ACS patients undergoing cardiac catheterization. At 30days, clopidogrel pretreatment was associated with lower MACE 7.67% vs 9.46% (odds ratio (OR) 0.77, 95% confidence interval (CI) [0.68, 0.86]; P<0.0001) and all-cause mortality 2.8% vs 4.1% (OR 0.70, 95% CI [0.58, 0.85]; P=0.0003). Mortality according to the longest follow up available was also significantly lower with pretreatment. No difference in major bleeding events was observed. These results were not significantly different between randomized vs observational studies or STEMI vs NSTEACS patients. Sensitivity analysis showed significantly lower MACE 7.98% vs 9.6% (OR 0.83, 95% CI [0.71, 0.96]; P=0.01) without increased major bleeding in NSTEACS patients undergoing PCI within 48h from pretreatment. CONCLUSION: In ACS patients undergoing PCI, clopidogrel pretreatment was associated with significantly lower 30day all-cause mortality and major adverse cardiovascular events without increased major bleeding events.
BACKGROUND: It is unknown whether pretreatment with clopidogrel in acute coronary syndrome (ACS) managed invasively, is superior to a strategy of administering clopidogrel in the cardiac catheterization laboratory at the time of percutaneous coronary intervention (PCI). Current practice guidelines do not endorse one strategy over the other. METHODS: A comprehensive literature search was done to identify all relevant studies comparing pretreatment with clopidogrel to administration in the cardiac catheterization laboratory at the time of PCI (no pretreatment). A meta-analysis using a random effects model was used to calculate outcomes of interest. RESULTS: Our search identified 16 studies including 61,517 ACS patients undergoing cardiac catheterization. At 30days, clopidogrel pretreatment was associated with lower MACE 7.67% vs 9.46% (odds ratio (OR) 0.77, 95% confidence interval (CI) [0.68, 0.86]; P<0.0001) and all-cause mortality 2.8% vs 4.1% (OR 0.70, 95% CI [0.58, 0.85]; P=0.0003). Mortality according to the longest follow up available was also significantly lower with pretreatment. No difference in major bleeding events was observed. These results were not significantly different between randomized vs observational studies or STEMI vs NSTEACS patients. Sensitivity analysis showed significantly lower MACE 7.98% vs 9.6% (OR 0.83, 95% CI [0.71, 0.96]; P=0.01) without increased major bleeding in NSTEACS patients undergoing PCI within 48h from pretreatment. CONCLUSION: In ACS patients undergoing PCI, clopidogrel pretreatment was associated with significantly lower 30day all-cause mortality and major adverse cardiovascular events without increased major bleeding events.
Authors: José Carlos Nicolau; Gilson Soares Feitosa Filho; João Luiz Petriz; Remo Holanda de Mendonça Furtado; Dalton Bertolim Précoma; Walmor Lemke; Renato Delascio Lopes; Ari Timerman; José A Marin Neto; Luiz Bezerra Neto; Bruno Ferraz de Oliveira Gomes; Eduardo Cavalcanti Lapa Santos; Leopoldo Soares Piegas; Alexandre de Matos Soeiro; Alexandre Jorge de Andrade Negri; Andre Franci; Brivaldo Markman Filho; Bruno Mendonça Baccaro; Carlos Eduardo Lucena Montenegro; Carlos Eduardo Rochitte; Carlos José Dornas Gonçalves Barbosa; Cláudio Marcelo Bittencourt das Virgens; Edson Stefanini; Euler Roberto Fernandes Manenti; Felipe Gallego Lima; Francisco das Chagas Monteiro Júnior; Harry Correa Filho; Henrique Patrus Mundim Pena; Ibraim Masciarelli Francisco Pinto; João Luiz de Alencar Araripe Falcão; Joberto Pinheiro Sena; José Maria Peixoto; Juliana Ascenção de Souza; Leonardo Sara da Silva; Lilia Nigro Maia; Louis Nakayama Ohe; Luciano Moreira Baracioli; Luís Alberto de Oliveira Dallan; Luis Augusto Palma Dallan; Luiz Alberto Piva E Mattos; Luiz Carlos Bodanese; Luiz Eduardo Fonteles Ritt; Manoel Fernandes Canesin; Marcelo Bueno da Silva Rivas; Marcelo Franken; Marcos José Gomes Magalhães; Múcio Tavares de Oliveira Júnior; Nivaldo Menezes Filgueiras Filho; Oscar Pereira Dutra; Otávio Rizzi Coelho; Paulo Ernesto Leães; Paulo Roberto Ferreira Rossi; Paulo Rogério Soares; Pedro Alves Lemos Neto; Pedro Silvio Farsky; Rafael Rebêlo C Cavalcanti; Renato Jorge Alves; Renato Abdala Karam Kalil; Roberto Esporcatte; Roberto Luiz Marino; Roberto Rocha Corrêa Veiga Giraldez; Romeu Sérgio Meneghelo; Ronaldo de Souza Leão Lima; Rui Fernando Ramos; Sandra Nivea Dos Reis Saraiva Falcão; Talia Falcão Dalçóquio; Viviana de Mello Guzzo Lemke; William Azem Chalela; Wilson Mathias Júnior Journal: Arq Bras Cardiol Date: 2021-07 Impact factor: 2.667