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.