0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review | Clinician's Corner

Association of Clopidogrel Pretreatment With Mortality, Cardiovascular Events, and Major Bleeding Among Patients Undergoing Percutaneous Coronary Intervention:  A Systematic Review and Meta-analysis

Anne Bellemain-Appaix, MD; Stephen A. O’Connor, MD; Johanne Silvain, MD, PhD; Michel Cucherat, MD, PhD; Farzin Beygui, MD, PhD; Olivier Barthélémy, MD; Jean-Philippe Collet, MD, PhD; Laurent Jacq, MD; François Bernasconi, MD; Gilles Montalescot, MD, PhD ; for the ACTION group
JAMA. 2012;308(23):2507-2516. doi:10.1001/jama.2012.50788.
Text Size: A A A
Published online

Context Clopidogrel pretreatment is recommended for patients with acute coronary syndromes (ACS) and stable coronary artery disease who are scheduled for percutaneous coronary intervention (PCI), but whether using clopidogrel as a pretreatment for PCI is associated with positive clinical outcomes has not been established.

Objective To evaluate the association of clopidogrel pretreatment vs no treatment with mortality and major bleeding after PCI.

Data Sources MEDLINE, EMBASE, Cochrane Controlled Trials Register databases, and reference lists of qualifying articles.

Study Selection Studies reporting clinical data on mortality and major bleeding were included. Of the 392 titles identified, 15 articles published between August 2001 and September 2012 met the inclusion criteria: 6 randomized controlled trials (RCTs), 2 observational analyses of RCTs, and 7 observational studies.

Data Extraction Quality of studies was assessed with the Ottawa Scale and the Jadad Score as appropriate. Results were independently extracted by 2 reviewers. A random-effect model was applied. Pretreatment was defined as the administration of clopidogrel before PCI or catheterization. The main analysis was performed on RCTs and confirmed by observational analyses and observational studies. Prespecified subgroups—clinical presentation and clopidogrel loading dose—were analyzed. The primary efficacy and safety end points were all-cause mortality and major bleeding. Secondary end points included major cardiac events.

Results Of the 37 814 patients included in the meta-analysis, 8608 patients had participated in RCTs; 10 945, in observational analyses of RCTs; and 18 261, in observational studies. Analysis of RCTs showed that clopidogrel pretreatment was not associated with a reduction of death (absolute risk, 1.54% vs 1.97%; OR, 0.80; 95% CI, 0.57-1.11; P =  .17) but was associated with a lower risk of major cardiac events (9.83% vs 12.35%; OR, 0 .77; 95% CI, 0.66-0.89; P < .001). There was no significant association between pretreatment and major bleeding overall (3 .57% vs 3.08%; OR, 1.18; 95% CI, 0.93-1.50; P = .18). Analyses from observational analyses of RCTs and observational studies were consistent for all results.

Conclusions Among patients scheduled for PCI, clopidogrel pretreatment was not associated with a lower risk of mortality but was associated with a lower risk of major coronary events.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Figures

Place holder to copy figure label and caption
Figure 1. Study Selection
Graphic Jump Location

References of the excluded articles are available at http://www.jama.com. CABG indicates coronary artery bypass; GPIIb/IIIa, glycoprotein IIb/IIIa; PCI, percutaneous coronary intervention; and RCT, randomized controlled trial.

Place holder to copy figure label and caption
Figure 2. All-Cause Mortality Analysis
Graphic Jump Location

aThe number of patients represent those who were followed up at 1 year.

Place holder to copy figure label and caption
Figure 3. Major Bleeding and Major Cardiovascular Event Analyses
Graphic Jump Location

For a definition of major bleeding for each study, see Table 1.aThe number of patients represents those who were followed up at 30 days.bThe number of patients represents those who were followed up at 1 year.

Tables

References

CME


You need to register in order to view this quiz.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

16,000 Views
36 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Related Multimedia

Author Interview

audio player

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

Users' Guides to the Medical Literature
Was the Individual Trial or Meta-Analysis Large Enough? Just Check the Confidence Intervals

Users' Guides to the Medical Literature

×
brightcove.createExperiences();