Perspective on COMMIT/CCS-2 Trial of Clopidogrel in STEMI Christopher Cannon, M.D. Brigham and...
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Perspective on COMMIT/CCS-2 Trial of Clopidogrel in STEMI Christopher Cannon, M.D. Brigham and Women’s Hospital Boston, MA
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Transcript of Perspective on COMMIT/CCS-2 Trial of Clopidogrel in STEMI Christopher Cannon, M.D. Brigham and...
Perspective on COMMIT/CCS-2 Trial of Clopidogrel in STEMI
Christopher Cannon, M.D.Brigham and Women’s Hospital
Boston, MA
Paradigm of Reperfusion Rx for Acute MI
Acute Coronary Occlusion
Myocardial Necrosis
LV Dysfunction
Death
ThrombolysisPrimary PCI
Recurrentinfarction
Antithrombotic
Therapy
Braunwald, E. Circulation 1989;79:441-4.
Milestones in the Evolution of Thrombolysis in Myocardial Infarction
Mortality
1988 ISIS-2 SK 25% ↓
ASA 23% ↓
1993 GUSTO-1 TPA 14%↓
2005 COMMIT/ Clopidogrel 7% ↓
CCS-2
Drugs that Failed to Show Mortality Reduction in STEMI in Past Decade
• Double-bolus t-PA• TNK• rPA• nPA• GP IIb/IIIa inhibition
+lytic• Oral GP IIb/IIIa
• Bivalirudin• Hirudin• Pexulizamab• Magnesium• Adenosine• PSGL• GIK
etc….
ST Elevation MI: Clopidogrel Trials
COMMIT/COMMIT/CCS-2CCS-2
46,000 Patients
Mortality, D/MI/CVA
AMI < 24 hrs
Age up to 100
~50% Lytic
No loading dose
China
Non-invasive Strategy
3,500 Patients
Infarct Artery Patency
AMI < 12 hrs
Age < 75
100% Fibrinolytic
Loading dose
Europe / N. Amer.
Invasive Strategy
Special Considerations for Clinical Use
• Bolus vs. no bolus– Benefit on clinical endpoints in both trials
emerged in first 24 hrs– CLARITY-TIMI 28: 20% benefit– COMMIT/CCS-2: 9% benefit
(~13% in Pts <12 hrs)
• Elderly: evidence for benefit in COMMIT– In Pts > 75 years : no loading dose– In Pts < 75 years: 300 mg loading dose
• Worldwide public health benefit (1 month <$100 vs. t-PA $2,200)
• No excess major bleeding in CABG
Clopidogrel in STEMI
• Evidence from 2 large trials in ~ 50,000 patients
• Benefit in opening infarct-related artery, and in reducing mortality and morbidity
• No excess in major bleeding
• Low cost
A new addition to treatment of STEMI
Clopidogrel Across Spectrum of CAD
COMMITCOMMIT(CCS-2)(CCS-2)
CAPRIECAPRIELancet 1996Lancet 1996
MI /Stroke/PAD High-RiskVascular Disease
Up to 3.5 years
STEMI
Acute STEMI Long-term 2o (1o)preventionUA/NSTEMI PCI
PCINSTEMI / UA
+ Benefit + Benefit
1 Year 1 Year
+ Benefit
1-3 Years30 Days
+ Benefit (ongoing)
