Use of early clopidogrel by reperfusion strategy among patients presenting with ST-segment elevation myocardial infarction

Background-The 2007 update of the ACC/AHA guidelines for STEMI patients recommended addition of clopidogrel to aspirin regardless of reperfusion strategy, with a bolus dose in patients <75 years of age. Methods and Results-We evaluated use and dose of early clopidogrel among 52,140 STEMI patients enrolled in 368 hospitals participating in NCDR's ACTION Registry® -Get with the Guidelines (GWTG™) from January 2007-September 2009. Patients were stratified by reperfusion strategy: primary percutaneous coronary intervention (PCI, n=37,108), fibrinolysis (n=5805), or no-reperfusion (n=9227), and by age (<75 or ≤75 years). Adjusted odds for in-hospital outcomes are reported by clopidogrel use across reperfusion strategies. Clopidogrel was administered early to 97% of primary PCI, 18% of fibrinolytic, and 6% of non-reperfused patients. Among patients receiving clopidogrel, a loading dose (≤300 mg) was often used in primary PCI (91%) but less frequently among fibrinolysis-treated (83%) and non-reperfused patients (74%). A positive time trend from Q1 2007-Q3 2009 in overall clopidogrel use was observed only in fibrinolytic patients (15-20%) Use of clopidogrel was associated with a significant increase in major bleeding only among older patients in the no-reperfusion group (21.9% vs. 13.2%; OR 2.19; 95% CI 1.47-3.27). A significantly lower risk of in-hospital death was associated with clopidogrel use across all reperfusion strategies (OR [95% CI], primary PCI: 0.15 [0.13-0.19]; fibrinolysis: 0.26 [0.12-0.57]; no reperfusion: 0.42 [0.27-0.65]). Conclusion-Early clopidogrel use has not yet extended to the routine care of STEMI patients treated with fibrinolysis or those not receiving reperfusion as recommended in the guideline update.