Role of Clopidogrel Loading Dose in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Angioplasty Results From the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) Trial

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

卷:54

Article

Dangas, George^1,2  Mehran, Roxana^1,2  Guagliumi, Giulio³  Caixeta, Adriano^1,2  Witzenbichler, Bernhard⁴  Aoki, Jiro^1,2  Peruga, Jan Z.⁵  Brodie, Bruce R.^6,7  Dudek, Dariusz⁸  Kornowski, Ran⁹  Rabbani, LeRoy E.¹  Parise, Helen^1,2  Stone, Gregg W.^1,2 

[1] Columbia Univ, Med Ctr, New York, NY 10022 USA

[2] Cardiovasc Res Fdn, New York, NY USA

[3] Osped Riuniti Bergamo, I-24100 Bergamo, Italy

[4] Charite Univ Med Campus Benjamin Franklin, Berlin, Germany

[5] Med Univ Lodz, Dept Cardiol, Bieganski Hosp, Lodz, Poland

[6] LeBauer Cardiovasc Res Fdn, Greensboro, NC USA

[7] Moses Cone Hosp, Greensboro, NC USA

[8] Jagiellonian Univ, Krakow, Poland

[9] Rabin Med Ctr, Petah Tiqwa, Israel

关键词: myocardial infarction;    angioplasty;    stent;    anticoagulants;   

DOI  :  10.1016/j.jacc.2009.06.021

来源: Elsevier

【 摘 要 】

Objectives Our aim was to determine whether a 600-mg loading dose of clopidogrel compared with 300 mg results in improved clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Background A 600-mg loading dose of clopidogrel compared with 300 mg provides more rapid and potent inhibition of platelet activation. Methods In the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial, 3,602 patients with STEMI undergoing primary PCI were randomized to bivalirudin (n = 1,800) or unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor (n = 1,802). Randomization was stratified by thienopyridine loading dose, which was determined before random assignment. Results Patients in the 600-mg (n = 2,158) compared with the 300-mg (n = 1,153) clopidogrel loading dose group had significantly lower 30-day unadjusted rates of mortality (1.9% vs. 3.1%, p = 0.03), reinfarction (1.3% vs. 2.3%, p = 0.02), and definite or probable stent thrombosis (1.7% vs. 2.8%, p = 0.04), without higher bleeding rates. Compared with unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor, bivalirudin monotherapy resulted in similar reductions in net adverse cardiac event rates within the 300-mg (15.2% vs. 12.3%) and 600-mg (10.4% vs. 7.3%) clopidogrel loading dose subgroups (P-interaction = 0.41). By multivariable analysis, a 600-mg clopidogrel loading dose was an independent predictor of lower rates of 30-day major adverse cardiac events (hazard ratio: 0.72 [95% confidence interval: 0.53 to 0.98], p = 0.04). Conclusions In patients with STEMI undergoing primary PCI with contemporary anticoagulation regimens, a 600-mg loading dose of clopidogrel may safely reduce 30-day ischemic adverse event rates compared with a 300-mg loading dose. (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction [HORIZONS-AMI]; NCT00433966) (J Am Coll Cardiol 2009;54:1438-46) (C) 2009 by the American College of Cardiology Foundation

【 授权许可】

Free