Published online before print June 15, 2009, doi: 10.1161/CIRCULATIONAHA.109.874552
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(Circulation. 2009;119:3168-3170.)
© 2009 American Heart Association, Inc.
Editorial |
Antiplatelet Polypharmacy in Primary Percutaneous Coronary Intervention
Trying to Understand When More Is Better
From the Gill Heart Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, Ky.
Correspondence to David J. Moliterno, MD, Division of Cardiovascular Medicine, University of Kentucky, 900 S Limestone, 317 Wethington Bldg, Lexington, KY 40536–0200. E-mail moliterno@uky.edu
Key Words: Editorials • angioplasty • aspirin • myocardial infarction • platelets
An extract of the first 250 words of the full text is provided, because this article has no abstract. |
Timely and sustained reperfusion in the ST-elevation myocardial infarction setting improves mortality, and primary percutaneous coronary intervention (PCI) is the guideline-favored revascularization strategy.1 Primary PCI requires pharmacological support with antiplatelet and antithrombin therapy, and many drugs and combinations are established for this purpose. Likewise, patients with ST-elevation myocardial infarction are at risk for subsequent ischemic events in the weeks to months after their index event, and long-term antiplatelet therapy is needed. Aspirin alone provides an inadequate effect on a substantial number of patients with atherosclerotic plaque rupture, whether the vascular disruption occurs as part of an acute coronary syndrome (ACS) or a PCI procedure. Indeed, patients with concomitant spontaneous plaque rupture (ie, troponin-positive ACS) and subsequent disruption from PCI have a particularly high rate of ischemic events with aspirin therapy alone and a notably large risk reduction with antiplatelet adjuncts, such as thienopyridines and glycoprotein IIb/IIIa inhibitors.
Article see p 3207
Platelet glycoprotein IIb/IIIa inhibitors have been studied in many placebo-controlled primary PCI trials. De Luca and colleagues performed a meta-analysis of such trials testing abciximab on 3949 patients. They reported an 
30% reduction in mortality at 6 to 12 months.2 When these studies were performed, procedural thienopyridine use was infrequent, and appropriate loading doses had not been established. Of the 8 primary PCI trials in the meta-analysis, only 2 described administration of a thienopyridine loading dose, and maintenance therapy was continued for only several weeks. Since then, clopidogrel use has become commonplace, yet for a variety of reasons a
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