Comparison of Efcacy and Safety of a Standard Versus a Loading

Dose of Clopidogrel for Acute Myocardial Infarction in Patients

>75 Years of Age (from the FAST-MI Registry)
Etienne Puymirat, MD
a,b,
*, Nadia Assaoui, MD
a,b
, Pierre Coste, MD
c
, Gilles Dentan, MD
d
,
Vincent Bataille, MSc
e
, Elodie Drouet, MSc
f
, Genevive Mulak, PharmD
g
, Dider Carri, MD, PhD
e
,
Didier Blanchard, MD
a,b
, Tabassome Simon, MD, PhD
f,h
, and Nicolas Danchin, MD, PhD
a,b
Data are lacking on the efcacy and safety of a loading dose (LD) of clopidogrel in elderly
patients with acute myocardial infarction (AMI). FAST-MI is a nationwide registry that
was carried out over a 1-month period in 2005 and included consecutive patients with AMI
admitted to intensive care units <48 hours from symptom onset in 223 participating
centers. We assessed the impact of a clopidogrel LD (>300 mg) compared to a conventional
dose (<300 mg) on bleeding, need for blood transfusion, and 30-day and 12-month
survivals in 791 elderly patients (>75 years old, mean age 81 4 years, 48% women, 35%
with ST-segment elevation MI) included in this registry. Fifty-nine percent (466 patients)
received a clopidogrel LD. Follow-up was >99% complete. Major bleeding and blood
transfusions were not signicantly different in patients who received a clopidogrel LD
(3.2% vs 3.7%, p 0.72; 5.4% vs 6.2%, p 0.64, respectively). Early mortality was also not
signicantly different (10.1 vs 10.8, p 0.76). Using multivariate analyses, clopidogrel LD
did not signicantly affect major bleeding or transfusion (odds ratio 1.03, 95% condence
interval 0.49 to 2.17, p 0.94) and 12-month mortality (hazard ratio 1.00, 95% condence
interval 0.72 to 1.40, p 0.98). In conclusion, the present data showed that in elderly
patients admitted for AMI, use of a LD of clopidogrel compared to a conventional dose was
not associated with increased in-hospital bleeding, need for transfusion, or mortality.
Large-scale randomized trials are still needed to identify the optimal LD of clopidogrel for
elderly patients admitted for AMI. 2011 Elsevier Inc. All rights reserved. (Am J Cardiol
2011;108:755759)
The objective of this study was to assess the impact of
using a loading dose (LD) of clopidogrel (300 mg) com-
pared to a conventional dose (300 mg) on major bleeding,
need for transfusion, and 12-month survival in elderly pa-
tients (75 years of age) with acute myocardial infarction
(AMI) from the French Registry of Acute ST-Elevation or
NonST-elevation Myocardial Infarction (FAST-MI) of the
French Society of Cardiology.
1
Methods
Patients 75 years of age receiving a known dose of
clopidogrel 48 hours of admission and participating in the
FAST-MI were included. Methods of the FAST-MI have
been described in detail elsewhere.
1
Briey, the primary
objectives were to evaluate practices for MI management in
real-life practice and to measure their impact on medium-
and long-term prognoses of patients admitted to intensive
care units (ICUs) for MI. This registry results from a pro-
spective multicenter (223 centers) study including 3,059
patients. Patients were recruited consecutively from ICU
departments over a period of 1 month (October 2005).
Participation in the study was offered to all French institu-
tions, university teaching hospitals, general and regional
hospitals, and private clinics with ICUs authorized to re-
ceive acute coronary syndrome (ACS) emergencies. In each
center, a physician was in charge of the registry and pro-
vided a full list of all patients admitted to the unit.
Inclusion criteria were (1) men or women 18 years old;
(2) patients admitted within 48 hours after symptom onset in
an ICU for an AMI characterized by increased troponin or
creatine kinase-MB associated with 1 of the following
elements: symptoms compatible with myocardial ischemia,
appearance of pathologic Q waves, or ST-T changes com-
patible with myocardial ischemia (ST-segment elevation or
depression, T-wave inversion); and (3) consent to take part
a
Division of Coronary Artery Disease and Intensive Cardiac Care,
Assistance Publique-Hpitaux de Paris, Hpital Europen Georges Pom-
pidou, Paris, France;
b
Faculty of Medicine, University Paris Descartes,
Paris, France;
c
Department of Cardiology, Hpital Haut-Lvque, Pessac,
France;
d
Department of Cardiology, Clinique de Fontaine, Dijon, France;
e
Department of Cardiology B, Department of Epidemiology, Institut Na-
tional de la Sante et de la recherche Medicale U558, Toulouse University
Hospital, Toulouse, France;
f
Assistance Publique des Hpitaux de Paris,
URC-EST, St. Antoine Hospital, Paris, France;
g
Socit Franaise de
Cardiologie, Paris, France;
h
UPMC-Paris, 06 University, Paris, France.
Manuscript received March 31, 2011; revised manuscript received and
accepted April 29, 2011.
FAST-MI is a registry of the French Society of Cardiology supported
by unrestricted grants from Pzer (New York, New York) and Servier
(Neuilly, France). Additional support was obtained from a research grant
from the Caisse Nationale dAssurance maladie (Paris, France).
*Corresponding author: Tel: 00-33-0-1-56-09-28-51; fax: 00-33-0-1-
56-09-25-71.
E-mail address: etiennepuymirat@yahoo.fr (E. Puymirat).
0002-9149/11/$ see front matter 2011 Elsevier Inc. All rights reserved. www.ajconline.org
doi:10.1016/j.amjcard.2011.04.028
in the study. Exclusion criteria were (1) refusal to partici-
pate, (2) MI admitted 48 hours after symptom onset, (3)
iatrogenic MIs, dened as MIs occurring within 48 hours of
a therapeutic procedure (bypass surgery, coronary angio-
plasty, or any other medical or surgical intervention), (4)
ACS diagnosis invalidated in favor of another diagnosis,
and (5) patients with unstable angina and no increase in
cardiac biomarkers.
1
The study was conducted in compliance with good clin-
ical practice, French law, and the French data protection
law. The protocol was reviewed by the committee for the
protection of human subjects in biomedical research of
Saint-Antoine University Hospital. The data le of the
FAST-MI was declared to and authorized by the French
data protection committee (Commission Nationale Informa-
tique et Libert).
Although the diagnosis of AMI was independently made
at each participating center, to avoid heterogeneous criteria,
ST-segment elevation MI was diagnosed when ST-segment
elevation 1 mm was seen in 2 contiguous leads in any
location on the index or qualifying electrocardiogram, and
nonST-segment elevation MI (nonQ-wave MI) was diag-
nosed when no ST-segment elevation was seen on the index
or qualifying electrocardiogram. Presence of a presumed
new left bundle branch block on admission electrocardio-
gram was also recorded. Patients who died very soon after
admission and for whom cardiac markers were not mea-
sured were included if they had compatible signs or symp-
toms associated with typical ST-segment changes. Partici-
pating in the protocol did not change the therapeutic
approach of the cardiologist in any way.
Baseline characteristics data, namely demographics (age,
gender, body mass index), risk factors (hypertension, body
mass index 30 kg/m
2
, diabetes, current smoking, hyper-
lipidemia), and medical history (previous AMI, previous
percutaneous coronary intervention [PCI], previous coro-
nary artery bypass grafting, previous stroke, chronic renal
failure, severe concomitant illness), were collected prospec-
tively and stored electronically as previously described.
1
For safety analyses, the decision was made to focus on
in-hospital major bleeding (dened as a decrease in hemo-
globin 5 g, decrease in hematocrit 15%, intracranial
hemorrhage, retroperitoneal bleeding) and transfusion. In
addition, patients discharged alive were followed for 12
months.
Statistical analysis was performed using SPSS 18.0
(SPSS, Inc., Chicago, Illinois). For quantitative variables,
mean SD and minimum and maximum values were
calculated. In addition, medians with interquartile ranges
were calculated for some variables. Discrete variables are
presented as percentage. Comparisons were performed with
chi-square or Fishers exact test for discrete variables and
by unpaired t test, Wilcoxon sign-rank test, or 1-way anal-
ysis of variance for continuous variables. Each relative risk
value is presented with its 95% condence interval (CI).
In-hospital survival is described as percentages and com-
parisons were made by chi-square test. Multivariate analy-
ses of predictors of short-term outcome (30 days) were
performed using stepwise multiple logistic regression anal-
ysis. Survival curves over the 1-year follow-up period were
estimated using KaplanMeier estimation and compared
using log-rank test. Correlates of 1-year survival were de-
termined using a multivariate stepwise Cox backward
model. Variables included in the nal multivariate models
are those with a signicance level 0.15 in univariate
analyses.
Results
Of the 3,059 patients included in the registry, 791 were
75 years and received a known dose of clopidogrel in the
rst 48 hours of admission in the ICU. Follow-up was 99%
complete.
Baseline characteristics are listed in Table 1; 466 patients
(59%) received an LD (300 mg, 300 mg in 384 patients,
375 mg in 5 patients, 450 mg in 16 patients, 600 mg in 60
patients, 900 mg in 1 patient) and 325 patients (41%) a
Table 1
Baseline characteristics according to loading dose of clopidogrel in
patients 75 years old
No LD
(n 325)
LD
(n 466)
p Value
Age (years) 82 5 81 4 0.02
Women 159 (49%) 224 (48%) 0.88
Body mass index (kg/m
2
) 25.9 4.4 26.1 4.3 0.53
Hypertension 255 (78.5%) 331 (71%) 0.02
Left ventricular ejection
fraction
50 13 50 14 0.79
Global registry of acute
coronary events score
174 32 171 30 0.09
Diabetes mellitus 96 (29.5%) 126 (27%) 0.44
Current smoking 29 (9%) 42 (9%) 0.93
Hyperlipidemia* 163 (50%) 214 (46%) 0.33
Previous myocardial
infarction
94 (29%) 75 (16%) 0.001
Previous percutaneous
intervention
70 (21.5%) 56 (12%) 0.001
Previous coronary artery
bypass grafting
31 (9.5%) 23 (5%) 0.02
Previous stroke 23 (7%) 28 (6%) 0.39
Chronic kidney disease 39 (12%) 28 (6%) 0.002
Severe co-morbidity 52 (16%) 70 (15%) 0.67
Previous clopidogrel use 117 (36%) 39 (8.4%) 0.001
Data are presented as number of patients (percentage) or mean SD.
* Included patients with previously documented diagnosis of hypercho-
lesterolemia treated with diet or medication or new diagnosis during this
hospitalization with increased total cholesterol 160 mg/dl; did not in-
clude increased triglycerides.
Table 2
Early complications according to clopidogrel loading dose
No LD
(n 325)
LD
(n 466)
p Value
Minor bleeding 4 (1.2%) 8 (1.7%) 0.58
Major bleeding 12 (3.7%) 15 (3.2%) 0.72
Transfusions 20 (6.2%) 25 (5.4%) 0.64
Major bleeding or
transfusions
20 (6.2%) 25 (5.4%) 0.64
In-hospital
mortality
33 (10.2%) 37 (7.9%) 0.28
Death at 30 days 35 (10.8%) 47 (10.1%) 0.76
Data are presented as number of patients (percentage).
756 The American Journal of Cardiology (www.ajconline.org)
conventional dose (75 mg in 287 patients, 150 mg in 27
patients, 225 mg in 11 patients) of clopidogrel during the
rst 48 hours. The 2 groups (LD and no LD) were similar in
many respects. However, patients treated without a clopi-
dogrel LD were slightly but signicantly older with more
hypertension, more chronic kidney disease, and more myo-
cardial revascularization than those treated with a clopi-
dogrel LD.
Early complications according to clopidogrel LD are
presented in Table 2. No difference was found in in-hospital
bleeding and 30-day mortality in patients treated with clopi-
dogrel LD versus conventional dose. A subgroup analysis of
early mortality and major bleeding as a function of clopi-
dogrel LD according to type of management in patients with
ST-segment elevation MI, use of glycoprotein IIb/IIIa re-
ceptor blockers, previous use of clopidogrel, and use of PCI
during hospital stay is presented in Table 3. No difference
was found in the different subgroups of patients treated with
clopidogrel LD versus conventional dose except in the sub-
group of patients without reperfusion therapy.
One-year survival (80.7% vs 73.5%) and 1-year event-
free survival (survival without recurrent MI or stroke,
77.3% vs 68.6%), however, were higher in patients treated
with clopidogrel LD (Figures 1 and 2). At 1 year propor-
Figure 1. KaplanMeier curve for overall survival at 1-year follow-up. HR
hazard ratio.
Figure 2. KaplanMeier curve for event-free survival at 1-year follow-up.
Abbreviation as in Figure 1.
Table 3
Complications according to clopidogrel loading dose by subgroup
Subgroups 30-Day Mortality Major Bleeding or Transfusions
No LD LD p Value No LD LD p Value
ST-segment elevation myocardial infarction
No reperfusion therapy (n 165) 63 102 63 102
10 (15.9%) 14 (13.7%) 0.70 5 (7.9%) 0 (0%) 0.01
Primary percutaneous coronary intervention
(n 108)
26 82 26 82
3 (11.5%) 8 (9.8%) 0.80 1 (3.8%) 5 (6.1%) 0.66
Intravenous brinolysis (n 66) 24 42 24 42
4 (16.7%) 6 (14.3%) 0.79 1 (4.2%) 1 (2.4%) 0.68
Glycoprotein IIb/IIIa blockers
No (n 572) 245 327 245 327
24 (9.8%) 36 (11.0%) 0.64 16 (6.5%) 15 (4.6%) 0.31
Yes (n 219) 80 139 80 139
11 (13.8%) 11 (7.9%) 0.17 4 (5.0%) 10 (7.2%) 0.52
Previous clopidogrel use
No (n 635) 208 427 208 427
20 (9.6%) 42 (9.8%) 0.93 9 (4.3%) 24 (5.6%) 0.49
Yes (n 156) 117 39 117 39
15 (12.8%) 5 (12.8%) 1.00 11 (9.4%) 1 (2.6%) 0.17
Percutaneous coronary intervention during
hospital stay
No (n 355) 179 176 179 176
25 (14.0%) 30 (17.0%) 0.42 10 (5.6%) 13 (7.4%) 0.49
Yes (n 436) 146 290 146 290
10 (6.8%) 17 (5.9%) 0.69 10 (6.8%) 12 (4.1%) 0.22
Data are presented as number of patients (percentage).
757 Coronary Artery Disease/Clopidogrel Loading Dose in Elderly Patients
tions of patients with recurrent MI (3.6% vs 4.6%, p 0.50)
and stroke (1.5% vs 3.4%, p 0.08) were also not different
between the 2 groups.
Using logistic regression analysis, there was no signi-
cant increase in risk of in-hospital bleeding or transfusion
using an LD (odds ratio 1.03, 95% CI 0.49 to 2.17, p
0.94). Likewise, risk of in-hospital death (odds ratio 0.91,
95% CI 0.50 to 1.68, p 0.77) and 30-day mortality (odds
ratio 1.15, 95% CI 0.65 to 2.02, p 0.63) were not signif-
icantly different in patients who received an LD. Using Cox
multivariate analysis, 12-month mortality also was not sig-
nicantly different in patients who had received a clopi-
dogrel LD (hazard ratio 1.00, 95% CI 0.72 to 1.40, p
0.98). Repeat MI and stroke-free survival also did not sig-
nicantly differ in patients receiving clopidogrel LD versus
conventional dose (hazard ratio 0.92, 95% CI 0.68 to 1.25,
p 0.61).
Discussion
The present data, gathered from a nationwide real-
world registry of patients admitted for AMI, indicate that
in an elderly population the use of a clopidogrel LD at the
acute stage of MI is not associated with an increase in major
bleeding or a signicant independent effect on mortality or
hard events at 1 year.
Compared to aspirin alone, results of randomized trials
have shown that clopidogrel plus aspirin decreases the risk
of ischemic events in patients undergoing PCI and in those
with ACS.
25
The benets of clopidogrel even without an
LD are well established. The Clopidogrel and Metoprolol in
Myocardial Infarction Trial/Second Chinese Cardiac Study
(COMMIT-CCS-2) randomized 45,852 patients within 24
hours of suspected MI and documented the benecial effect
of adding a conventional 75-mg dose of clopidogrel in
addition to aspirin in ischemic events. In this study 26% of
patients were 70 years of age and patients received intra-
venous brinolysis or medical therapy only.
6
Efcacy of the
conventional clopidogrel dose compared to placebo was
similar in elderly and younger patients, and these results
form the basis of current recommendations that a conven-
tional 75-mg dose of clopidogrel should be used in patients
with ST-segment elevation MI without reperfusion therapy
or in elderly patients treated with brinolysis.
7
Currently
there is very little clinical evidence to recommend or dis-
courage the use of a clopidogrel LD in elderly patients.
An oral clopidogrel LD is typically used to achieve more
rapid platelet inhibition.
8,9
Greater platelet inhibition is asso-
ciated with a lower risk of ischemic events in patients under-
going PCI with stents.
1018
Likewise, insufcient platelet in-
hibition may be especially problematic when PCI is performed
in the thrombogenic milieu of patients with ACS.
19
However,
the optimum LD of clopidogrel has not been established.
Randomized trials establishing its efcacy and providing data
on bleeding risks used an LD of 300 mg orally followed by an
oral dose of 75 mg/day in patients with ACS.
20,21
At this LD
inhibition of platelet aggregation is approximately 30% to 40%
and time to peak effect is approximately 4 to 6 hours. Several
studies have shown greater inhibition with faster onset of
action with a 600-mg compared to a 300-mg clopidogrel LD,
which may be important in patients with ST-segment elevation
MI in whom time from thienopyridine administration to PCI is
short.
12,18
Increasing the dosage from 300 to 600 mg increases
platelet aggregation inhibition to 40% and signicantly de-
creases the incidence of clopidogrel hyporesponsiveness. Re-
cently a meta-analysis demonstrated that intensied clopi-
dogrel with 600 mg decreased the rate of major cardiovascular
events without increasing major bleeding compared to 300 mg
in patients undergoing PCI. This study included 20,904 pa-
tients (82%) undergoing PCI because of ACS. In these patients
a higher clopidogrel LD was associated with a 24% relative
risk decrease in major adverse cardiovascular events but was
not associated with an increased risk of major bleedings.
22
Results of the Clopidogrel Optimal Loading Dose Usage to
Reduce Recurrent Events/Optimal Antiplatelet Strategy for
Interventions (CURRENT-OASIS) 7 trial also showed a ben-
ecial effect of a 600- versus a 300-mg dose in patients un-
dergoing PCI.
23
In our study most patients received a clopi-
dogrel LD (59%), mainly 300 mg. Benets of the LD in 1-year
survival and ischemic events were no longer signicant after
multivariate adjustment.
Current guidelines on myocardial revascularization recom-
mend that patients with ACS receive a clopidogrel LD 600 mg
followed by 75 mg/day, whereas the American College of
Cardiology/American Heart Association recommended a
clopidogrel LD 300 to 600 mg as soon as possible before or at
the time of primary or nonprimary PCI.
24,25
There is, however,
no specic recommendation for elderly patients, although
guidelines imply that an LD also should be used in these
patients. Conversely, only the 75-mg dose is recommended for
elderly patients treated with intravenous brinolysis or a med-
ical strategy.
Our study has the same limitations as all observational studies,
namely no causality can be asserted between parameters that are
correlated. Comparisons between patients receiving a standard
dose to those receiving an LDwere not randomized and the results
can be considered only indicative. The size of our population was
also small. Different conventional doses and LDs were used. All
doses used were included because these data reect real-world
situations. However, results are similar if we consider only pa-
tients receiving a standard dose of 75 mg and those receiving a LD
of 300 mg. The precise dose was not recorded in 19 of 810
patients who received clopidogrel at the acute stage, so our anal-
ysis was limited to the 791 patients in whomthe dose was known.
We have no information in this registry on degree of platelet
inhibition.
Our data show that a clopidogrel LD as used in real-world
clinical practice in elderly patients (75 years of age) is safe and
not associated with a signicant increase in risk of major bleeding
or transfusion, even in patients receiving intravenous brinolysis.
After multivariate adjustment, however, 1-year mortality was not
signicantly lower compared to that observed in patients who
received a conventional dose of clopidogrel. Further studies are
still needed to identify the optimal antiplatelet therapy regimen in
elderly patients admitted for ACS.
Acknowledgment: The authors are deeply indebted to the
physicians who cared for the patients at the participating
institutions, to Nadine Roumier, MSc, from the Interna-
tional Clinical Trials Association contract research organi-
zation (Fontaine-ls-Dijon, France), and to the devoted per-
758 The American Journal of Cardiology (www.ajconline.org)
sonnel of the Unit de Recherche Clinique de Lest Parisien
(Assistance Publique des Hpitaux de Paris and University
Paris 6) and Institut National Sant Recherche Mdicale
U558 (Toulouse). Special thanks to Benot Pace, MSc (So-
cit Franaise de Cardiologie) for his invaluable assistance
in designing the electronic Case Report Form and to the
personnel of the registry committee of the Socit Franaise
de Cardiologie. A complete list of participating centers and
investigators can be found in a study by Cambou et al.
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