Myocardial infarction: angioplasty: stenting: fewer deaths and bleeds occurred with ticlopidine and aspirin.

Clinical bottom line (level 1b)

  1. Patients who had a recent MI and a successful coronary stent placement had fewer early clinical events if they had aspirin and ticlopidine rather than aspirin and warfarin (NNT = 6 at 30 days) .
  2. Patients also had fewer early non-cardiac events (NNT = 9 at 30 days) , fewer bleeds (NNT = 8 at 30 days) and fewer had reocclusion of the stented vessels (NNT = 10 at 30 days) .
  3. After 6 months, fewer patients were dead or had recurrent MI (NNT = 10 at 6 months) , though there was no clear difference in the overall cardiac event rate.
  4. There was no clear effect on restenosis rates.
Schomig et al: Journal of the American College of Cardiology 1997; 29: 28-34
Expires June 2003

The study

Unblinded concealed randomised trial with intention-to-treat
Setting: acute hospital, Germany

123 patients (aged mean 60 years, 76% male) had recent myocardial infarction (<48 hours) and successful coronary stent placement

Excluded if
  • contraindications to the study drugs
  • indications for anticoagulant therapy
  • cardiogenic shock, mechanical ventilation or both before angioplasty


    • Control Group: (n = 62, 62 analysed): heparin (adjusted so aPTT 80-100 seconds), followed by phenprocoumon . Continued heparin for 5-10 days until stable oral anticoagulation was achieved (INR 3.5 to 4.5)
    Experimental Group: (n = 61, 61 analysed): ticlopidine 250 mg twice daily for four weeks. Heparin infusion was stopped after 12 hours
    All patients received aspirin (100 mg twice daily) and were hospitalised for less than 14 days. Repeat angiography was done at six months.
    100% followed for 6 months
    Outcome notes:
    • any clinical event : death, MI, repeat revascularisation, stroke, bleed, peripheral vascular event
    • bleeding : requiring surgery or transfusion
    • cardiac events : cardiac death, MI, revascularisation

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    any clinical event 30 days 13
    (21.0%)    		 2
    (3.28%)    		 84%
    (34% to 96%)    		 17.7%
    (6.61% to 28.8%)    		 6
    (3 to 15)
    non-cardiac event 30 days 8
    (12.9%)    		 1
    (1.64%)    		 87%
    (1% to 98%)    		 11.3%
    (2.33% to 20.2%)    		 9
    (5 to 43)
    occlusion of stent vessel 30 days 6
    (9.68%)    		 0
    (0.00%)    		 100%
    (% to %)    		 9.68%
    (2.32% to 17.0%)    		 10
    (6 to 43)
    bleeding 30 days 8
    (12.9%)    		 0
    (0.00%)    		 100%
    (% to %)    		 12.9%
    (4.56% to 21.3%)    		 8
    (5 to 22)
    cardiac events 6 months 15
    (24.2%)    		 11
    (18.0%)    		 25%
    (-49% to 63%)    		 6.16%
    (-8.22% to 20.5%)    		 16
    (NNT = 5 to infinity;
    NNH = 12 to infinity)
    death or recurrent MI 6 months 6
    (9.68%)    		 0
    (0.00%)    		 100%
    (% to %)    		 9.68%
    (2.32% to 17.0%)    		 10
    (6 to 43)
    restenosis 6 months 14
    (22.6%)    		 13
    (21.3%)    		 6%
    (-84% to 52%)    		 1.27%
    (-13.4% to 15.9%)    		 79
    (NNT = 6 to infinity;
    NNH = 7 to infinity)

  • This is a sub study of a larger study comparing ticlopidine to classical anticoagulation treatment after stent placement during balloon angioplasty, and has the difficulties of retrospective data analysis.
  • Patients had stents inserted due to coronary artery dissection, complete vessel occlusion, residual diameter stenosis = 30% after angioplasty.

    • Citation

    1. Schomig A, Neumann FJ, Walter H, et al: Coronary stent placement in patients with acute myocardial infarction: comparison of clinical and angiographic outcome after randomization to antiplatelet or anticoagulant therapy. Journal of the American College of Cardiology 1997; 29: 28-34
    Search Terms: unstable angina in Best Evidence
    Contributor: Chris Ball and Clare Wotton, June 2000
    Reviewer: Christian Torp-Pedersen

    Clinical Question.
    Patient recent MI
    Intervention or Exposure ticlopidine
    Comparison phenprocoumon
    Outcome any clinical event