Patients given the anti-clotting drug Plavix before undergoing surgical procedures to open coronary arteries reduce their risk of heart attack but not overall death risk, according to new research.
Treatment with Plavix (clopidogrel) is recommended before patients with heart attack or unstable angina (chest pains) undergo procedures such as angioplasty and stenting.
However, it hadn't been determined whether giving patients Plavix before these procedures improves their outcomes. So, researchers reviewed data from more than 37,000 patients who took part in 15 studies published between 2001 and 2012.
According to a team led by Dr. Anne Bellemain-Appaix of La Fontonne Hospital in Antibes, France, pretreatment with Plavix before angioplasty/stenting was associated with a reduced risk of major coronary events.
For example, about 4.5 percent of patients who took Plavix suffered a heart attack, compared with about 6 percent of those who didn't take the drug. About 10 percent of those taking Plavix had a "major coronary event" (heart attack or angina) versus more than 12 percent not on the drug, the team found.
However, the study saw no significant change in patients' overall risk for death from any cause, which was around 1.5 percent to nearly 2 percent, regardless of whether or not they took Plavix.
One expert in the United States said that the study seems to support Plavix's use as pretreatment in some cases.
While no overall survival benefit was noted, "other benefits besides an improved survival rate are seen in this analysis, such as heart attack, stroke, or the need for emergency surgery," said Dr. Kenneth Ong, acting chief of the department of cardiology at the Brooklyn Hospital Center, in New York City.
Of course, blood thinners can also raise a patient's bleeding risk. But the new study found that Plavix pretreatment was not associated with any significantly increased risk of major bleeding (3.57 percent with Plavix vs. about 3.1 percent without).
"So while the goal of reducing death has not been shown, use of Plavix before stenting can still be beneficial with no increase in major complications such as bleeding," Ong noted.
Patients who had suffered a severe type of heart attack, called ST-segment elevation myocardial infarction (STEMI), appeared to gain the most benefit from Plavix pretreatment, the authors said. In contrast, patients undergoing elective angioplasty or stenting had no apparent benefit from Plavix pretreatment. According to the researchers, that raises questions about the use of the drug in low-risk patients.
"The value of pretreatment, including with new (anti-clotting) agents, needs to be assessed in large prospective studies," the researchers concluded.
Dr. Stephen Green is associate chairman of the department of cardiology at North Shore University Hospital in Manhasset, N.Y. He said that the French review "predominantly confirms what most cardiologists who put stents into people already know, [that] the sicker the patient, the more likely the Plavix is going to be useful."
He added, however, that newer blood thinners have also come onto the market recently.
"Newer alternatives to Plavix include Effient and Brillinta," Green said. "They work quicker, and thus might not require being given as earlier as the Plavix. Plavix needs to be metabolized in the body for it to work, and can take several hours."
But the new agents are also more expensive, and have their own concerns, he added.
"Effient can cause more bleeding, and Brillinta has to be given twice a day," Green said. "Doctors today use all three agents, and try to individualize to the patient which of these three medications would be best for that patient."
The study was published in the Dec. 19 issue of the Journal of the American Medical Association.
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