Mortality Risk and Weight

1
Adjunctive, Combination,and Long-Term
Antiplatelet Therapy in High-Risk Patients
Peter B. Berger, MD, FACC Geisinger Medical
CenterDanville, PA
2
Combination Therapy

• Combining a thienopyridine with aspirin is
  beneficial in many clinical situations
• After stent placement (5 randomized trials ISAR,
  FANTASTIC, STARS, MATTIS, Hall)
• Acute coronary syndrome (CURE)

3
Study Characteristics
Lancet 2001
JAMA 2002
JAMA 2005
Sabbatine M et al. Presented at ESC 2006
4
CV Death, MI, or Stroke Following PCI
Without GPI
Trial Clop Pre-Rx No Pre-Rx PCI-CURE 27/1039
(2.6) 39/988 (3.9) CREDO 26/473 (5.5) 34/519
(6.6) PCI-CLARITY 22/639 (3.4) 30/615
(4.9) OVERALL 75/2151 (3.5) 103/2122
(4.9) Trial Clop Pre-Rx No
Pre-Rx PCI-CURE 14/274 (5.1) 23/357
(6.4) CREDO 29/427 (6.8) 32/396
(8.1) PCI-CLARITY 12/288 (4.2) 28/310
(9.0) OVERALL 55/989 (5.6) 83/1063 (7.8)
Favors Pre-Rx
Favors No Pre-Rx
OR 0.72 (0.53-0.98) P.03
1.0
0.25
2.0
0.5
With GPI
OR (95 CI)
P.85 for heterogeneityby GPI use
OR 0.69 (0.47-1.00) P.05
1.0
0.25
2.0
0.5
Sabbatine M et al. Presented at ESC 2006
OR (95 CI)
5
Individual Efficacy Outcomes
Clop No Outcome GPI Pre-Rx Pre-Rx
N 0.8 1.0 CV
Death Y 1.0 2.0 All 0.9 1.3 N 2.5 3.7 MI
Y 4.6 5.9 All 3.2 4.4 N 0.3 0.6 Stroke Y
0.2 0.4 All 0.3 0.5 N 3.5 4.9 D/MI/Strok
e Y 5.6 7.8 All 4.1 5.8
Favors Pre-Rx
Favors No Pre-Rx
OR 0.75 (0.44-1.29)
OR 0.71 (0.55-0.93)
OR 0.48 (0.19-1.24)
OR 0.71 (0.56-0.90) P.004
1.0
0.25
2.0
0.5
Sabbatine M et al. Presented at ESC 2006
OR (95 CI)
6
Bleeding Outcomes
Clop No Bleeding GPI Pre-Rx Pre-Rx N 0.7 0.9
Major Y 1.3 1.4 All 0.9 1.1 N 1.2 0.9 M
inor Y 2.0 1.1 All 1.4 1.0 N 1.9 1.6 Maj
Minor Y 3.2 2.5 All 2.3 1.9
Favors Pre-Rx
Favors No Pre-Rx
OR 0.81 (0.42-1.57)
OR 1.54 (0.90-2.63)
OR 1.21 (0.85-1.72) P.29
1.0
0.25
4.0
0.5
2.0
OR (95 CI)
Sabbatine M et a. Presented atl ESC 2006
7
The Random Argentine Clopidogrel Cardiology
Society (RACS) Trial
ASA, Heparin, Clopidogrel 300 mg Before or
Immediately After PCI gt1 Stent Placed
Successfully
Immediately Before Discharge, Randomization
Clopidogrel 75 mg/day for 6 Months
Clopidogrel 75 mg/dayfor 1 Month
Bernardo V et al. Am J Cardiol. In press
8
RACS Adverse Events, 30 Days 6 Months
No difference in event rates, enrollment 30 days
P.051
10
PNS
8.67
8

5.63
5.43
6
4.99
3.91
4
2.81
2.6
1.74
1.52
2
0.86
0.21
0
0
Death
MI
TVR
Stroke
Death,
Death,
MI,
MI,
Stroke
Stroke,
30 Days (n461)
6 Months (n460)
TVR
Bernardo V et al. Am J Cardiol. In press