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ESC Congress 2020 Register

Intensive antiplatelet therapy may be harmful in MINOCA

ESC Congress News 2019 - Paris, France

Treatment with intensive antiplatelet regimens may increase the risk of subsequent events in patients with myocardial infarction (MI) without obstructive coronary artery disease (MINOCA).

Antiplatelet Drugs
Cardiovascular Pharmacotherapy


This is what Doctor Matthias Bossard (Luzerner Kantonsspital, Luzern, Switzerland) will present in a session on MINOCA this afternoon (Abstract 2387).

“MINOCA is a broad category and there are currently no uniform recommendations for antiplatelet therapy use in these patients,” says Dr. Bossard. “To try to address this, we compared the data for MINOCA and non-MINOCA patients treated in the large CURRENT-OASIS 7 trial,1 which investigated the impact of double-dose clopidogrel (600 mg day 1; 150 mg days 2–7; then

75 mg daily) vs standard-dose clopidogrel (300 mg day 1; then 75 mg daily) in patients presenting with acute coronary syndromes (ACS).” The primary endpoint was a combination of cardiovascular death, MI and stroke. MINOCA patients—who accounted for 6.7% of the 28,783 included patients with MI—tended to be younger, more likely to have non-ST-segment elevation MI and had fewer comorbidities than non-MINOCA patients. In addition, rates of all-cause mortality, cardiovascular mortality, repeat MI and major bleeding were <1% in MINOCA patients and 3–4-times lower than those in non-MINOCA patients.

The findings were clear, but unexpected. “Since plaque erosion or rupture, thromboembolism, spontaneous coronary dissection and microvascular disorders are commonly encountered in MINOCA patients, we had thought that an intensified antiplatelet regimen may offer some benefits to these low-risk patients,” says Dr. Bossard. “Instead, what we saw was that double-dose clopidogrel more than tripled the risk of cardiovascular death, MI and stroke compared with standard-dose therapy in patients with MINOCA (hazard ratio [HR] 3.57; p=0.013).” This increased risk with intensified therapy was not seen in patients with obstructive coronary artery disease (CAD). Double-dose clopidogrel did not increase the rate of major bleeding in MINOCA patients (HR 0.99; p=0.987) compared with the standard dose, but it did in patients with obstructive CAD (HR 1.26; p=0.010). “Although these data need to be interpreted with caution since they stem from a post-hoc analysis of a large ACS trial, it seems to send out an important signal. One needs to take into account that we should not put all patients with ACS into the same pot,” says Dr. Bossard. “There is currently no good evidence for the routine use of intensive antiplatelet therapy in MINOCA and our results—which pave the way for more clinical trials in this setting—suggest that doctors should be very cautious using such treatment in these patients.”

Don’t miss!

MINOCA – Unravelling the enigma
Today, 16:40 – 17:50; Helsinki – Village 8

 

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References

  1. CURRENT-OASIS 7 Investigators. N Engl J Med 2010;363:930–942.

Notes to editor

About the European Society of Cardiology

The European Society of Cardiology brings together healthcare professionals from more than 150 countries, working to advance cardiovascular medicine and help people lead longer, healthier lives.

About ESC Congress 2019

ESC Congress is the world’s largest and most influential cardiovascular event contributing to global awareness of the latest clinical trials and breakthrough discoveries. ESC Congress 2019 takes place 31 August to 4 September at the Paris Expo Porte de Versailles, Paris - France. Explore the scientific programme