Platelet inhibition at the time of a
percutaneous coronary intervention has consistently been shown to decrease the risk of thrombotic adverse events but not restenosis. The role of enhanced antiplatelet protection through pretreatment with the platelet
ADP-receptor antagonist ticlopidine in preventing both the early and late complications of coronary stenting has not previously been explored.
METHODS AND RESULTS: In the Evaluation of Platelet IIb/IIIa Inhibitor for Stenting (EPISTENT) trial, approximately 1600 patients were randomized to stenting with either placebo or
abciximab in addition to
aspirin and
heparin. All stented patients also received
ticlopidine after the procedure, but 58% of these patients were given
ticlopidine before stenting at the discretion of the investigating physician. Among patients randomized to placebo,
ticlopidine pretreatment was associated with a significant decrease in the incidence of the composite end point of death,
myocardial infarction, or target vessel revascularization (TVR) at 1 year (adjusted hazard ratio, 0.73; 95% CI, 0.54 to 0.98; P:=0.036).
Ticlopidine pretreatment did not significantly influence the risk of death or
myocardial infarction in patients randomized to
abciximab. Controlling for patient characteristics and for the propensity of being on
ticlopidine, Cox proportional hazards regression identified
ticlopidine pretreatment as an independent predictor of the need for TVR at 1 year (hazard ratio, 0.62; 95% CI, 0.43 to 0.89; P:=0.010) in both placebo-treated and
abciximab-treated patients.
CONCLUSIONS: In the EPISTENT trial, among patients randomized to stenting, starting
ticlopidine before the
percutaneous coronary intervention was associated with a significant decrease in the incidence of the 12-month composite end point for patients not receiving
abciximab and the need for TVR among all patients.