冠動脈造影前の抗凝固療法

血管形成術施行予定の患者に冠動脈造影後にクロピドグレルを内服させた方が冠動脈造影前に非選択的にクロピドグレルを内服させるよりもよい
Post-angiography use of clopidogrel for patients going to angioplasty is superior to nonselective use of clopidogrel before elective coronary angiography
チェコ共和国のスタディの結果、クロピドグレルは待機的な冠動脈造影前の患者に非選択的に内服させるよりも、冠動脈造影後に冠動脈形成術施行予定の患者に内服させた方がよいことが示唆された、とESCで発表された。冠動脈造影の前日に1,028人の患者を、冠動脈造影前にクロピドグレル600mgを内服する群、または冠動脈造影後に冠動脈形成術を施行することになった患者のみに同用量を投与する群に無作為に割り分けた。複合一次エンドポイント（死亡／冠動脈形成術に関連した心筋梗塞、脳卒中または一過性脳虚血発作／7日以内の冠動脈形成術再施行）は両群ともに0.8%に発現した。一方、出血の合併症は非選択的投与群で3.5%に発現したのに対し血管形成術施行患者のみの群におけるその割合は1.2%であった。冠動脈形成術を施行された患者のみを解析すると一次エンドポイント発現率に有意差はなかった（非選択的使用群で1.3%、血管形成術施行患者のみで2.2%）。
Full Text

A multi-center Czech study suggests it is better to give clopidogrel after elective coronary angiography to patients who will undergo angioplasty than to use medication nonselectively prior to elective angiography, according to a presentation at the annual meeting of the European Society of Cardiology.

 

The current study was designed to address the question whether clopidogrel should be administered as pre-treatment to all patients undergoing elective coronary angiography with the aim to ensure therapeutic levels at the time of possible ad-hoc angioplasty.

 

The randomized trial enrolled 1,028 patients in five participating hospitals in the Czech Republic. All patients underwent elective angiography. On the day before their procedure, patients were randomized to group A (“nonselective” - clopidogrel 600 mg to all patients more than 6 hours before angiography, 513 patients) or group B (“selective” - clopidogrel 600 mg in the cath-lab after angiography only to patients undergoing subsequent angioplasty; 515 patients).

 

The combined primary end-point was death / periprocedural myocardial infarction / stroke or transient ischemic attack / re-intervention within seven days. Secondary end-points were troponin elevation, TIMI-flow after angioplasty, and bleeding complications.

 

Angioplasty immediately following angiography was performed in 29 percent of study patients. Bypass surgery was performed later in 12 percent of patients (mostly after more than seven days). Medical therapy was indicated in 59 percent of patients. Primary end-point occurred in 0.8 percent in both groups (a nonsignificant difference).

 

Bleeding complications occurred in 3.5 percent of group A patients versus 1.2 percent of group B (a significant difference). Periprocedural troponin elevation was detected in 2.7 percent of group A versus 3.0 percent of group B (nonsignificant difference).

 

When only the subgroup of patients who underwent angioplasty was analyzed, primary end-point occurred in 1.3 percent of group A versus 2.2 percent of group B (nonsignificant). Periprocedural troponin elevation was detected in 8.6 percent of group A versus 11.1 percent of group B (nonsignificant). Bleeding complications occurred in 7.2 percent of group A versus 0.7 percent of group B and reintervention within seven days in 0.7 percent of group A versus 1.5 percent group B (nonsignificant).

 

The authors concluded that clopidogrel pretreatment before elective angiography is not justified because it increases the risk of bleeding complications, while the benefit on periprocedural infarction is not significant. Use of Clopidogrel only for patients who will undergo angioplasty after angiography can be done safely in the catheterization laboratory between the two procedures.