Ticlopidine plus aspirin is better than oral anticoagulants alone for reducing the risk of revascularization, non-fatal myocardial infarction and bleeding following stenting of coronary arteries

Stents are placed in arteries around the heart (coronary arteries) to keep formerly blocked arteries open. A blood clot (thrombus) may form in the coronary artery after stenting and cause acute myocardial infarction (fatal or non-fatal) or more surgery. Blood thinners must be given for a short time to prevent clotting. Ticlopidine plus aspirin reduce the risk of complications after coronary stenting with less bleeding when compared to standard treatment (oral anticoagulants). Ticlopidine plus aspirin have other side effects such as bone marrow toxicity. Strict monitoring of blood-cell counts is recommended during treatment.

Authors' conclusions: 

Ticlopidine plus aspirin after coronary stenting is effective in reducing the risk of the revascularization, non fatal myocardial infarction and bleeding complications when compared with oral anticoagulants. No effect is observed on total mortality. However, the haematological side effects of ticlopidine are still a matter of concern, and strict monitoring of blood-cell counts is recommended. Physicians should also be aware of the possibility of rare although potentially life-threatening complications such as TTP

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Background: 

A two to four week course of ticlopidine plus aspirin following coronary stenting is considered effective in preventing thrombotic occlusion of the stented vessel and safe in regards to bleeding and peripheral vascular complications. However, rare, although potentially life-threatening haematological complications have been reported with this drug regimen.

Objectives: 

To evaluate the efficacy and safety of ticlopidine plus aspirin versus oral anticoagulants after coronary stenting

Search strategy: 

Electronic search of the Cochrane Library, Medline, Embase from 1991 to June 1999; references from trials and experts.

Selection criteria: 

Randomised controlled trials comparing ticlopidine plus aspirin versus oral anticoagulants (either with or without aspirin) after elective or bail out coronary stenting.

Data collection and analysis: 

Three reviewers assessed trial quality and compiled data on outcomes including: total mortality, non fatal myocardial infarction and revascularization occurring within the first 30 days after hospitalization, stent thrombosis on angiography, major and minor bleeding, neutropenia, thrombocytopenia, thrombotic thrombocytopenic purpura.

Main results: 

Four trials (n = 2436 patients) were included. Ticlopidine plus aspirin compared to oral anticoagulants significantly reduced the risk of non-fatal acute myocardial infarction and revascularization at 30 days, combined negative events (mortality, myocardial infarction, revascularization at 30 days) (RR: 0.41; 95% CI: 0.25 to 0.69; NNT for 30 days: 22; 95% CI: 14 to 45), and major bleeding (RR in high quality studies: 0.24 ; 95% CI: 0.07 to 0.79). Ticlopidine plus aspirin compared to oral anticoagulants significantly increased the risk of eutropenia,thrombocytopenia and neutropenia (RR 5; 95% CI: 1.08 to 13.07; NNT for 30 days: 142; 95% CI: 76 to 1000). Ticlopidine plus aspirin versus oral anticoagulation did not affect all cause mortality. Ticlopidine plus aspirin significantly reduced the risk of stent thrombosis (angiography) which was seen only on studies with blinded outcome assessment (RR: 0.14; 95% CI: 0.03 to 0.60; NNT for 30 days: 33; 95% CI:16 to 166). Minor bleeding was reported only in one study and no studies recorded thrombotic thrombocytopenic purpura (TTP).

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