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ARTICLE

Triple antiplatelet therapy during percutaneous coronary intervention is associated withimproved outcomes including one-year survival

Results from the do tirofiban and reoprogive similar efficacy outcome trial (TARGET)

Albert W. Chan, MD^*, David J. Moliterno, MD^,*, Peter B. Berger, MD, Gregg W. Stone, MD, Peter M. DiBattiste, MD^||, Steven L. Yakubov, MD^¶, Shelly K. Sapp, MS^#, Kathy Wolski, MPH^#, Deepak L. Bhatt, MD, Eric J. Topol, MD TARGET Investigators^**

^* Department of Cardiology, Ochsner Clinic Foundation, New Orleans, Louisiana, USA
Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Division of Cardiology, Mayo Clinic Foundation, Rochester, Minnesota, USA
Lenox Hill Heart and Vascular Institute, New York, New York, USA
^|| Merck, West Point, Pennsylvania, USA
^¶ Riverside Methodist Hospital, Columbus, Ohio, USA
^# Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Manuscript received December 12, 2002; revised manuscript received April 22, 2003, accepted May 9, 2003.

^* Reprint requests and correspondence: Dr. David J. Moliterno, Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk F25, Cleveland, Ohio 44195.
molited{at}ccf.org

OBJECTIVES: We sought to examine if clopidogrel treatment initiated before coronary stenting improved clinical outcomes among patients receiving aspirin and a glycoprotein (GP) IIb/IIIa inhibitor.

BACKGROUND: Antiplatelet therapy plays a pivotal role in contemporary percutaneous coronary interventions (PCI).

METHODS: Outcomes among 4,809 patients randomized to tirofiban or abciximab during PCI with stent placement were compared according to whether they received 300 mg of clopidogrel before PCI (93.1%) versus immediately after the procedure.

RESULTS: The 30-day primary composite end point (death, myocardial infarction [MI], or urgent target vessel revascularization [TVR]) was lower among clopidogrel-pretreated patients (6.6% vs. 10.4%, p = 0.009), mainly because of reduction of MI (6.0% vs. 9.5%, p = 0.012). The benefit of clopidogrel pretreatment was sustained at six months (death, MI, any TVR: 14.6% vs. 19.8%, HR = 0.71, p = 0.010), and this was due mainly to lowering of death and MI (7.8% vs. 13.0%, p = 0.001). At one year, clopidogrel pretreatment was associated with a lower mortality rate (1.7% vs. 3.6%, p = 0.011). Because clopidogrel pretreatment was not randomized, multivariable and propensity analyses were performed. After adjusting for baseline heterogeneity, clopidogrel pretreatment was an independent predictor for death or MI at 30 days (HR = 0.63, p = 0.012) and at six months (HR = 0.61, p = 0.003), and survival at one year (HR = 0.53, p = 0.044). No excess in 30-day bleeding events was noted with clopidogrel pretreatment.

CONCLUSIONS: Among patients undergoing coronary stent placement with aspirin and a GP IIb/IIIa inhibitor, clopidogrel pretreatment is associated with a reduction of death and MI irrespective of the type of GP IIb/IIIa inhibitor used.

Abbreviations and Acronyms   ACS = acute coronary syndrome   ADP = adenosine diphosphate   CREDO = Clopidogrel for Reduction of Events During Observation   EPISTENT = Evaluation of Platelet IIb/IIIa Inhibitor for Stenting   GOLD = Assessing Ultegra-AU Study   GP = glycoprotein   MI = myocardial infarction   PCI = percutaneous coronary intervention   PCI-CURE = PCI substudy of the Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial   TIMI = Thrombolysis In Myocardial Infarction   TVR = target vessel revascularization

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