Guidelines for early clopidogrel use not being followed
MedWire News: Contrary to US guideline recommendations, early clopidogrel use has not yet extended to the routine care of ST-segment-elevation myocardial infarction (STEMI) patients treated with fibrinolysis or reperfusion therapy, a study shows.
The American College of Cardiology/American Heart Association STEMI guidelines were updated in 2007 to recommend clopidogrel administration in addition to aspirin for all STEMI patients, regardless of whether they undergo reperfusion therapy (primary percutaneous coronary intervention [PCI] or fibrinolysis), explain Chiara Melloni (Duke University Medical Center, Durham, North Carolina, USA) and co-workers.
In addition, the guidelines suggest a loading dose (300 mg) of clopidogrel for patients younger than 75 years who receive fibrinolysis or no reperfusion, and no loading dose in those aged 75 years or older.
Melloni and team evaluated the administration of early clopidogrel, defined as use within the first 24 hours after STEMI.
The study included 52,140 STEMI patients treated at 368 hospitals participating in the National Cardiovascular Data Registry Early Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines database.
Patients were stratified according to treatment with reperfusion strategy: primary PCI (n=37,108), fibrinolysis (n=5805), or no-reperfusion (n=9227), and by age (<75 years or ≥75 years).
The findings, reported in the journal Circulation: Cardiovascular Quality and Outcomes, demonstrated that clopidogrel was administered early to 97% of primary PCI, 18% of fibrinolytic, and 6% of non-reperfused patients.
Among the patients receiving clopidogrel, a loading dose was often administered to primary PCI (91%), but less frequently to fibrinolysis-treated (83%), and non-reperfused patients (74%).
Use of clopidogrel in patients over the age of 75 years, which is not recommended by the guidelines, was associated with a significant increase in major bleeding among non-reperfused patients, and not in fibrinolytic patients.
Further analysis revealed that a significantly lower risk for inhospital death was associated with clopidogrel use across all reperfusion strategies.
"These results demonstrate the challenges associated with the translation of evidence from clinical trials into routine practice and suggest that efforts in performance improvement around early clopidogrel use are needed," conclude the authors.
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By Piriya Mahendra