Clinical Review

Clopidogrel in acute coronary syndromes

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b1180 (Published 14 April 2009) Cite this as: BMJ 2009;338:b1180
  1. Doson Chua, clinical pharmacotherapeutic specialist,
  2. Andrew Ignaszewski, head, division of cardiology
  1. 1St Paul’s Hospital, Department of Pharmacy, Vancouver, BC V6Z 1Y6, Canada
  1. Correspondence to: D Chua dchua{at}providencehealth.bc.ca
  • Accepted 26 January 2009

Summary points

  • All patients presenting with acute coronary syndromes should be given a 300 mg loading dose of clopidogrel, then 75 mg daily

  • Patients not undergoing percutaneous coronary intervention should receive clopidogrel for nine to 12 months for non-ST elevation myocardial infarction and 14 days for ST elevation myocardial infarction

  • Patients given a bare metal stent should receive clopidogrel, in addition to aspirin, for at least one month and ideally for one year

  • Patients given a drug eluting stent should receive clopidogrel, in addition to aspirin, for at least one year

  • The duration of clopidogrel treatment must take into account the patient’s risk of bleeding

Clopidogrel is well established in the treatment of acute coronary syndromes and is ubiquitous in cardiology practice. Landmark studies have established the importance of clopidogrel in the treatment of non-ST and ST elevation myocardial infarction and in percutaneous coronary intervention by reducing death, reinfarction, and adverse cardiac events. Knowledge of the benefits, risks, and duration of clopidogrel treatment is important for clinicians caring for patients presenting with and recovering from acute coronary syndromes. This review examines the recent key trials of clopidogrel in the treatment of acute coronary syndromes, as well as current cardiac guidelines from several professional societies.

Sources and selection criteria

We reviewed the most recent guidelines from the American College of Cardiology, National Institute for Health and Clinical Excellence, European Society of Cardiology, and American College of Chest Physicians on the use of clopidogrel in myocardial infarction. The landmark trials discussed in the above guidelines were retrieved for further review. We also searched for subsequent publications in this area by the key authors of the landmark trials. We searched Medline, Cochrane Library, and Embase using the terms “clopidogrel”, “thienopyridine”, “myocardial infarction”, “acute coronary syndrome”, “percutaneous coronary intervention”, “coronary stent”, and “coronary artery disease” for any additional landmark studies, …

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