Pharmacological treatment during AMI and in secondary prevention: the scientific evidence

Table 7a. Antiplatelet therapy in myocardial infarction. Effect on mortality.
STUDIES DRUG No. PATIENTS FOLLOW-UP VAR. P
During infarction
ISIS-2 (1988) [45] ASPIRIN 160 mg 17,187 15 MONTHS - 19% < 0.001
APRICOT (1991) [61] ASPIRIN 325 mg 300 3 MONTHS -- NS
After infarction
AMIS (1980) [6] ASPIRIN 1000 mg 4,524 3 YEARS + 11% 0.02
PARIS I (1980) [72] ASA 325mg /ASA + DIPYRIDAMOLE 2,026 3 YEARS - 12% NS
PARIS II (1986) [53] ASPIRIN 325mg + DIPYRIDAMOLE 3,128 23 MONTHS - 2% NS
CAPRIE (1996) [28] CLOPIDOGREL 75 mg vs ASA 325 mg 6,302 1.91 YEARS +3.7% NS

 

META-ANALYSES No. STUDIES No. PATIENTS VAR. P
During infarction
YUSUF (1988) [100] 2 17,600 -21% <0.0001
BASINSKI (1991) [8] 13 NR -23% 0.02
ROUX (1992) [82] 32 3,698 -20% 0.001
ANTIPLATELET TRIALISTS’ COLL. (1994) [4] 9 18,773 -29%* <0.00001
After infarction
YUSUF (1988) [100] 10 18,500 -11% <0.01
ANTIPLATELET TRIALISTS’ COLL. (1994) [4] 11 19,791 - 25%* <0.0001

NR = not reported
* myocardial infarction, stroke and vascular death

 

ACC/AHA GUIDELINES

  • Class I (1996):
    • A dose of 160 to 325 mg should be given on day 1 of AMI and continued indefinitely on a daily basis.
  • Class IIb (1996):
    • Other antiplatelet agents such as dipyridamole or ticlopidine may be substituted if true aspirin allergy is present.
  • Class IIb (1999):
    • Other antiplatelet agents such as dipyridamole, ticlopidine, or clopidogrel may be substituted if true aspirin allergy is present or if the patient is unresponsive to aspirin.

ANMCO-SIC CLINICAL GUIDELINES

ASA, 160 mg/die, should be given to all patients after AMI without contraindications (active peptic ulcer, haemorrhagic diathesis, allergy)

 

Table 7b. Antiplatelet therapy with glycoprotein iib/iiia inhibitors in Acute Coronary Syndromes/Unstable Angina. Effect on mortality.
STUDY DRUGS No.PATIENTS FOLLOW-UP VAR P
PRISM-PLUS (1998) [74] Tirofiban vs Heparin vs Tirofiban + Heparin 1,915 6 MONTHS -1.4% NS
PRISM (1998) [73] Tirofiban vs Heparin 3,232 30 DAYS -36% 0.02
PARAGON (1998) [69] Lamifiban (low-high dose) vs Heparin 2,282 1 YEAR -17% NS
PURSUIT (1998) [75] Eptifibatide vs Placebo 10,948 30 DAYS -5% NS

 

ACC/AHA GUIDELINES

  • Class IIa (1996):
    • no indications
  • Class IIa (1999):
    • For use in patients experiencing an MI without ST-segment elevation who have some high-risk features and/or refractory ischemia, provided they do not have a major contraindication due to a bleeding risk.

ANMCO-SIC CLINICAL GUIDELINES

No indications