title: Use of early clopidogrel by reperfusion strategy among patients presenting with ST-segment elevation myocardial infarction.
abstract: 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.
  
  
  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]).
  
  
  CONCLUSIONS
  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.
authors: Division of Cardiology and Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt St, Durham, NC 27705, USA. mello004@mc.duke.edu
authors: Chiara
authors: C
authors: Melloni
authors: Matthew T
authors: MT
authors: Roe
authors: Anita Y
authors: AY
authors: Chen
authors: Tracy Y
authors: TY
authors: Wang
authors: Stephen D
authors: SD
authors: Wiviott
authors: P Michael
authors: PM
authors: Ho
authors: Eric D
authors: ED
authors: Peterson
authors: Karen P
authors: KP
authors: Alexander
mesh_terms: D000279:Administration, Cutaneous; D000368:Aged; D017130:Angioplasty; D000077144:Clopidogrel; D003331:Coronary Vessels / Q000187:drug effects / Q000473:pathology / Q000601:surgery*; D004562:Electrocardiography; D005260:Female; D005342:Fibrinolysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology / Q000601:surgery; D017410:Practice Guidelines as Topic; D015424:Reperfusion / Q000379:methods; D016019:Survival Analysis; D013988:Ticlopidine / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D000077144:Clopidogrel; D013988:Ticlopidine