Use of early clopidogrel by reperfusion strategy among patients presenting with ST-segment elevation myocardial infarction.

BACKGROUND: The 2007 update of the ACC/AHA guidelines for STEMI patients recommended addition of clopidogrel to aspirin regardless of reperfusion strategy, with a bolus dose in patients <75 years of age. METHODS AND RESULTS: We evaluated use and dose of early clopidogrel among 52,140 STEMI patients enrolled in 368 hospitals participating in NCDR's ACTION Registry®--Get with the Guidelines (GWTG™) from January 2007-September 2009. Patients were stratified by reperfusion strategy: primary percutaneous coronary intervention (PCI, n=37,108), fibrinolysis (n=5805), or no-reperfusion (n=9227), and by age (<75 or ≥75 years). Adjusted odds for in-hospital outcomes are reported by clopidogrel use across reperfusion strategies. Clopidogrel was administered early to 97% of primary PCI, 18% of fibrinolytic, and 6% of non-reperfused patients. Among patients receiving clopidogrel, a loading dose (≥300 mg) was often used in primary PCI (91%) but less frequently among fibrinolysis-treated (83%) and non-reperfused patients (74%). A positive time trend from Q1 2007-Q3 2009 in overall clopidogrel use was observed only in fibrinolytic patients (15-20%) Use of clopidogrel was associated with a significant increase in major bleeding only among older patients in the no-reperfusion group (21.9% vs. 13.2%; OR 2.19; 95% CI 1.47-3.27). A significantly lower risk of in-hospital death was associated with clopidogrel use across all reperfusion strategies (OR [95% CI], primary PCI: 0.15 [0.13-0.19]; fibrinolysis: 0.26 [0.12-0.57]; no reperfusion: 0.42 [0.27-0.65]). CONCLUSION: Early clopidogrel use has not yet extended to the routine care of STEMI patients treated with fibrinolysis or those not receiving reperfusion as recommended in the guideline update.

Duke Scholars

Author Chiara Melloni Medicine, Cardiology

Author Matthew Todd Roe Medicine, Cardiology

Author Karen Patton Alexander Medicine, Cardiology