Therapy

Following stent insertion, give clopidogrel 300 mg bolus ^a , then 75 mg daily for one month.  ^a  

Less effective alternatives include

• ticlopidine  ^a
• warfarin and aspirin ^a

Why?

• Adding ticlopidine to aspirin following stenting is more effective than anticoagulation and aspirin at reducing occlusion of the stented vessel, bleeding, and myocardial infarction or death. ^a   However adverse effects from ticlopidine severe enough to discontinue therapy are common (particularly neutropenia ) ^a
• Adding clopidogrel to aspirin compared with ticlopidine leads to fewer deaths ^b , cardiac events ^b , and complications (bleeding, thrombocytopenia, neutropenia). ^a  
• Using a loading dose of clopidogrel reduces complications. ^a

Fewer patients on clopidogrel die or have a cardiac event than on ticlopidine

Patient	Treatment	Comparison	Outcome	CER	OR (95% CI)	NNT (95% CI)
successful coronary artery stenting b	clopidogrel and aspirin	ticlopidine and aspirin	cardiac event at 30 days	4.0%	0.72 (0.59 to 0.89)	90 (62 to 230)
			death at 30 days	1.1%	0.55 (0.37 to 0.82)	210 (150 to 510)

Clopidogrel causes fewer  complications than ticlopidine, especially with a loading dose

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
successful coronary artery stenting a	clopidogrel and aspirin	ticlopidine and aspirin	complications at 4 weeks	9.1%	50% (16% to 69%)	22 (13 to 89)
	loading dose of clopidogrel	no loading dose	complications at 4 weeks	6.3%	54% (3% to 78%)	30 (51 to 440)

Ticlopidine reduces death, myocardial infarction and bleeding better than anticoagulation.

Patient	Treatment	Comparison	Outcome	CER	RRR (95% CI)	NNT (95% CI)
recent MI: angiography with insertion of stent a	ticlopidine and aspirin	anticoagulation and aspirin	occlusion of stent vessel at 30 days	9.7%	100%	10 (6 to 43)
			bleeding at 30 days	13%	100%	8 (5 to 22)
			death or recurrent MI at 6 months	9.7%	100%	10 (6 to 43)