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Optimal pre-PCI 600mg clopidogrel loading: PRAGUE-8.

Acute Coronary Syndromes (ACS)

Clopidogrel pre-treatment before planned PCI was proved to reduce periprocedural complications. However, majority of patients do not undergo planned PCI, but rather "ad-hoc“ PCI performed a few minutes after coronary angiography. Whether clopidogrel should be administered as pre-treatment to all pts undergoing elective coronary angiography with the aim of ensuring therapeutic levels at the time of possible ad-hoc PCI is not known.

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1028 patients undergoing elective coronary angiography were randomized to group A (“nonselective” - clopidogrel 600 mg > 6 hours before CAG; n = 513) or group B (“selective” - clopidogrel 600 mg in the cath-lab after CAG, only to patients undergoing subsequent PCI; n = 515). The combined primary end-point was death / periprocedural myocardial infarction / stroke or transient ischemic attack / re-intervention within 7 days. Secondary end-points were troponin elevation and bleeding complications.
The primary end-point occurred in 0.8% in both groups (non significant, NS). Bleeding complications occurred in 3.5% of group A patients vs. 1.2% in group B (p = 0.02). Periprocedural troponin elevation (> 3x ULN) was detected in 2.7% in group A vs. 3.0% in group B (NS).

When only the patients who underwent PCI were analyzed, primary end-point occurred in 1.3% in group A vs. 2.2% in group B (NS). Periprocedural troponin elevation was detected in 8.6% (group A) vs. 11.1% (group B, NS). Bleeding complications occurred in 7.2% (group A) vs. 0.7% (group B, p = 0.006).


Routine clopidogrel pretreatment before elective coronary angiography is not justified – it increases the risk of bleeding complications, while the benefit on periprocedural infarction is not significant. Clopidogrel should be given only to patients with known coronary angiography who undergo PCI and this can be done safely in the catheterization laboratory between the two procedures.




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The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.