How to optimally prepare a patient for planned coronary angiography and subsequent angioplasty?
Methods: This randomized trial enrolled 1,028 patients in five participating hospitals in the Czech Republic. All patients underwent elective CAG, i.e. invasive imaging of their coronary arteries. On the day before CAG patients were randomized to group A ("nonselective" - clopidogrel 600 mg to all patients > 6 hours before CAG; n = 513) or group B ("selective" - clopidogrel 600 mg in the cath-lab after CAG, only to patients undergoing subsequent PCI; n = 515). Combined primary end-point was death / periprocedural myocardial infarction / stroke or transient ischemic attack / re-intervention within 7 days. Secondary end-points were troponin elevation, TIMI-flow after PCI, bleeding complications.
Results: Ad-hoc PCI (i.e. PCI immediately following CAG) was performed in 29% of study patients. and bypass surgery (CABG) in 12 % of patients (mostly after >7 days). Medical therapy was indicated in 59% of patients. Primary end-point occurred in 0,8% in both groups (n.s.). Bleeding complications occurred in 3,5% group A patients vs. 1,2% group B (p = 0,02). Periprocedural troponin elevation (i.e. very small infarction as a complication of the procedure) was detected in 2,7% group A vs. 3,0% group B (n.s.).
When only the subgroup of patients who underwent PCI was analyzed, primary end-point occurred in 1,3% group A vs. 2,2% group B (n.s.). Periprocedural troponin elevation was detected in 8,6% (group A) vs. 11,1% (group B, n.s.). Bleeding complications occurred in 7,2% (group A) vs. 0,7% (group B, p = 0,006) and reintervention within 7 days in 0,7% group A vs. 1,5% group B (n.s.).
Conclusion: Routine clopidogrel pretreatment before elective CAG is not justified - it increases the risk of bleeding complications, while the benefit on periprocedural infarction is not significant. Clopidogrel should be given only to patients with known CAG who undergo PCI and this can be done safely in the catheterization laboratory between the two procedures.
Notes to editors:
This study was presented at the ESC Congress 2007 in Vienna.
The European Society of Cardiology (ESC):
The ESC represents nearly 53,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.
The ESC achieves this through a variety of scientific and educational activities including the coordination of: clinical practice guidelines, education courses and initiatives, pan-European surveys on specific disease areas and the ESC Annual Congress, the largest medical meeting in Europe. The ESC also works closely with the European Commission and WHO to improve health policy in the EU.
The ESC comprises 3 Councils, 5 Associations, 19 Working Groups, 50 National Cardiac Societies and an ESC Fellowship Community (Fellow, FESC; Nurse Fellow, NFESC). For more information on ESC Initiatives, Congresses and Constituent Bodies see www.escardio.org.
European Society of Cardiology, The European Heart House 2035 Route des Colles, B.P. 179 - Les Templiers, Sophia Antipolis F-06903 France
About the Author(s)
Professor Petr Widimský
Charles University & Univ. Hospital Kralovske Vinohrady Prague, Czech Republic
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