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1.
EuroIntervention ; 4(2): 214-21, 2008 Aug.
Article in English | MEDLINE | ID: mdl-19110786

ABSTRACT

AIMS: Our prospective study sought to investigate whether inadequate platelet responses to clopidogrel can be corrected by increasing the daily maintenance dose from 75 mg to 150 mg. METHODS AND RESULTS: In 117 patients with elective PCI after loading with 600 mg clopidogrel, we determined residual platelet aggregation in response to 5 micromol/l ADP (RPA) by optical aggregometry after the first 75 mg maintenance dose (baseline), and at days 14 and 28. In patients with RPA >14% at baseline, we increased the daily dose to 150 mg. Fifty-seven additional patients without dose adjustment served as historic control. In 39 patients with baseline RPA >14%, the increase in maintenance dose to 150 mg reduced median RPA significantly (P<0.001) from 24% [interquartile range: 18-32%] at baseline to 14% [8-20%1 at 14 days without any further significant change. In patients with RPA < or = 14%, who continued on 75 mg clopidogrel, RPA increased during the first 14 days by 4.5% (0-14%; P<0.001). At 14 days, the study group with selective dose adjustment had a significantly lower RPA than the control group without dose adjustment (10.0% [4-20%1 versus 17.0% [9-32%], P<0.001). CONCLUSIONS: In patients with a low initial response to clopidogrel, platelet inhibition can be improved by increasing the maintenance dose to 150 mg.


Subject(s)
Angioplasty, Balloon, Coronary , Myocardial Ischemia/therapy , Platelet Activation/drug effects , Platelet Aggregation Inhibitors/administration & dosage , Thrombosis/prevention & control , Ticlopidine/analogs & derivatives , Aged , Clopidogrel , Dose-Response Relationship, Drug , Female , Follow-Up Studies , Humans , Male , Middle Aged , Stents , Ticlopidine/administration & dosage
2.
J Am Coll Cardiol ; 51(20): 1925-34, 2008 May 20.
Article in English | MEDLINE | ID: mdl-18482659

ABSTRACT

OBJECTIVES: We investigated whether the loss of function CYP2C19 681G>A *2 polymorphism is associated with high (>14%) residual platelet aggregation (RPA) on clopidogrel and whether high on-clopidogrel RPA impacts clinical outcome after elective coronary stent placement. BACKGROUND: The cytochrome P450 (CYP)-dependent conversion of clopidogrel to its active metabolite may contribute to the variability in antiplatelet effect of clopidogrel. METHODS: The study included 797 consecutive patients undergoing percutaneous coronary intervention, who were followed-up for 1 year. Adenosine-diphosphate-induced (5 mumol/l) RPA was assessed after a 600-mg loading dose and after the first 75-mg maintenance dose of clopidogrel before discharge. CYP2C19 genotype was analyzed by real-time polymerase chain reaction. RESULTS: Of the patients included, 552 (69.3%) were CYP2C19 wild-type homozygotes (*1/*1) and 245 (30.7%) carried at least one *2 allele. Residual platelet aggregation at baseline did not differ significantly between genotypes. On clopidogrel, RPA was significantly (p < 0.001) higher in *2 carriers than in wild-type homozygotes (23.0% [interquartile range (IQR) 8.0% to 38.0%] vs. 11.0% [IQR 3.0% to 28.0%] after loading; 11.0% [IQR 5.0% to 22.0%] vs. 7.0% [IQR 3.0% to 14.0%] at pre-discharge). Between *2 carriers and wild-type homozygotes, we found significant (p < 0.001) differences in the proportion of patients with RPA >14%, both after loading (62.4% vs. 43.4%) and at pre-discharge (41.3% vs. 22.5%). Residual platelet aggregation >14% at pre-discharge incurred a 3.0-fold increase (95% confidence interval 1.4 to 6.8; p = 0.004) in the 1-year incidence of death and myocardial infarction. CONCLUSIONS: Patients carrying at least one CYP2C19*2 allele are more prone to high-on clopidogrel platelet reactivity, which is associated with poor clinical outcome after coronary stent placement (Effect of Clopidogrel Loading and Risk of PCI [EXCELSIOR]; NCT00457236).


Subject(s)
Angioplasty, Balloon, Coronary/adverse effects , Aryl Hydrocarbon Hydroxylases/genetics , Mixed Function Oxygenases/genetics , Platelet Aggregation Inhibitors/pharmacology , Platelet Aggregation/drug effects , Polymorphism, Genetic , Ticlopidine/analogs & derivatives , Aged , Angioplasty, Balloon, Coronary/mortality , Clopidogrel , Cytochrome P-450 CYP2C19 , Drug-Eluting Stents/adverse effects , Female , Humans , Male , Middle Aged , Myocardial Infarction/etiology , Myocardial Infarction/mortality , Platelet Aggregation Inhibitors/therapeutic use , Ticlopidine/pharmacology , Ticlopidine/therapeutic use , Treatment Outcome
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