Antiplatelet therapy for STEMI: The Case for Clopidogrel Sunil V. Rao MD FACC FSCAI The Duke Clinical Research Institute Duke University Medical Center

Off-label uses of drugs/devices may be discussed Disclosures Consultant, Honoraria The Medicines Company, Terumo Medical, ZOLL Research funding Bellerophon Off-label uses of drugs/devices may be discussed

Clopidogrel in STEMI You know how you sound, Mr. Blaine? Like a man who's trying to convince himself of something he doesn't believe in his heart.

Clopidogrel – preferred in STEMI Clopidogrel is once daily Clopidogrel is generic and affordable Clopidogrel has lower bleeding risk Clopidogrel has fewer contraindications than some newer P2Y12 inhibitors

Compliance higher with QD Impact of daily dosing frequency on adherence N=10697 pts with atrial fibrillation; QD vs. BID meds MPR PDC PDC – proportion of days covered MPR – medication possession ratio 1.0 Compliance higher with QD Laliberte F, et. al. Adv Ther 2012

Ticagrelor vs. Clopidogrel in STEMI N=7544 with STEMI Ticagrelor prevented 42 MIs but at the Expense of 21 strokes Steg PG, et. al. Circulation 2010

Ticagrelor vs. Clopidogrel in STEMI: Major bleeding N=7544 with STEMI Steg PG, et. al. Circulation 2010

Prasugrel vs. Clopidogrel in STEMI N=3544 patients with STEMI CV Death/MI/Stroke CV Death/MI/uTVR Stent thrombosis TIMI Major bleeding Montalescot G, et. al. Lancet 2009

Net Clinical Benefit: Bleeding Risk Subgroups Post hoc analysis Risk (%) Yes +37 Prior Stroke/TIA No Pint = 0.006 -16 ≥75 -1 Age <75 Pint = 0.18 -16 <60 kg +3 Weight ≥60 kg Pint = 0.36 -14 -13 0.5 1 2 Prasugrel Better Clopidogrel Better HR Wiviott et al. N Engl J Med. 2007;357:2001.

Clopidogrel – preferred in STEMI Clopidogrel is once daily Clopidogrel is generic and affordable Clopidogrel has lower bleeding risk Clopidogrel has fewer contraindications than some newer P2Y12 inhibitors

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