High clopidogrel dose not beneficial after MINOCA
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Patients with MI with nonobstructive coronary arteries, or MINOCA, have fewer recurrent events than those with MI and obstructive CAD, but double-dose clopidogrel was more harmful in MINOCA, according to CURRENT-OASIS 7 trial data.
“Despite increasing data on the characteristics and prognosis of patients presenting with MINOCA, studies assessing therapies and, thus, evidence-based guidelines for the treatment of MINOCA are still limited,” Matthias Bossard, MD, cardiologist at Luzerner Kantonsspital in Lucerne, Switzerland, and colleagues wrote. “It remains unclear as to whether patients with MINOCA derive similar benefit from dual antiplatelet therapy as compared with patients with MI with obstructive CAD.”
In a post hoc analysis of the CURRENT-OASIS 7 trial, researchers evaluated 23,783 patients (mean age, 62 years, 74% men) with MI (6.7% with MINOCA) for the associations between clopidogrel drug dosage and the composite outcome of MI, stroke or CV death.
Patients received a standard 300 mg clopidogrel loading dose followed by a 75 mg per day dosage or a 600 mg double clopidogrel loading dose followed by a 150 mg dose per day; all patients received a 75 mg dose per day from day 8 to day 30. The study concluded at 30 days.
Compared with patients with obstructive CAD, patients with MINOCA had lower rates of all-cause mortality (0.6% vs. 2.2%; P = .006), repeat MI (0.5% vs. 2.3%; P = .001) and major bleeding (0.6% vs. 2.4%; P < .0001).
In those with MI but obstructive CAD, there was no difference in double-dose vs. standard dose clopidogrel for the composite outcome (4.3% vs. 4.7%, respectively; HR = 0.91, 95% CI, 0.8-1.03). However, in those with MINOCA, those receiving double-dose clopidogrel had higher rates of the composite outcome than those receiving the standard dose (2.1% vs. 0.6%; HR = 3.57; 95% CI 1.31-9.76; P for interaction = .011).
“Patients with MINOCA are at lower risk of recurrent CV events compared with patients with MI with obstructive CAD. Compared with a standard clopidogrel-based DAPT regimen, an intensified dosing strategy appears to offer no additional benefit and may even be harmful,” Bossard and colleagues concluded. “There is a need for prospective studies evaluating optimal antiplatelet therapy regimens in patients with MINOCA.”
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