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ISCHAEMIC HEART DISEASE
Clopidogrel is useful in addition to aspirin in AMI ▸
In > 45 000 patients, the addition of 75 mg clopidogrel < 24 hours after ST elevation myocardial infarction (STEMI), in addition to aspirin and reperfusion, was assessed. Treatment was to continue until discharge or up to four weeks in hospital (mean 15 days in survivors) and 93% of patients completed it. The two prespecified co-primary outcomes were: (1) the composite of death, reinfarction, or stroke; and (2) death from any cause during the scheduled treatment period. Comparisons were by intention to treat, and used the log rank method. Allocation to clopidogrel produced a highly significant 9% (95% confidence interval (CI) 3% to 14%) proportional reduction in death, reinfarction, or stroke (2121 (9.2%) clopidogrel v 2310 (10.1%) placebo; p = 0.002), corresponding to 9 (SE 3) fewer events per 1000 patients treated for about two weeks. There was also a significant 7% (95% CI 1% to 13%) proportional reduction in any death (1726 (7.5%) v 1845 (8.1%); p = 0.03). Considering all fatal, transfused, or cerebral bleeds together, no significant excess risk was noted with clopidogrel, either overall (134 (0.58%) v 125 (0.55%); p = 0.59), or in patients aged older than 70 years or in those given fibrinolytic treatment.
Intravenous metoprolol < 24 hours after STEMI does not improve prognosis ▸
Using the same population as for the COMMIT study, the use of early intravenous β blocker treatment was also assessed. For death, reinfarction, or cardiac arrest, 2166 (9.4%) patients allocated metoprolol had at least one such event compared with 2261 (9.9%) allocated placebo (odds ratio (OR) 0.96, 95% CI 0.90 to 1.01; p = 0.1). For death alone, there were 1774 (7.7%) deaths in the metoprolol group versus 1797 (7.8%) in the placebo group (OR 0.99, 95% CI 0.92 to 1.05; p = 0.69). Any benefit in terms of reinfarction and arrhythmias was balanced by an increase in cardiogenic shock …
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