Ever since since the modern era of treatment of heart attacks, we have use aspirin, blood thinning with heparins, and have hit the platelets, the cels that control clotting, with powerful drugs such as clopiodgrel, as soon as a diagnosis is suspected. That made sense when it too over a week for the cardiologist to see you and for you to get an angiogram. Now, you will be seen by cardiology within 24 hours, and will have an angiogram probably within 48 hours. So does it make sense to still give these drugs? The benefit is in reducing the chance of setting off a further heart attack. The risk is in setting of bleeding.
Recent research suggests that the pretreatment corners no benefit in terms of reducing death rate, but definately increases bleeding risk. There was a slight benefit in terms of heart attack deduction. The ACTION investigators suggest that these results will hold for those treated with stents and those with medical therapy alone. They also hold true for prasugrel or Clopiodgrel. The third big drug, Ticagrelor was not looked at.
So should we change practice? Probably not yet but we should not stress if the patient arrives without Clopiodgrel on board. We can treat once we know the anatomy on angiography. Strangely, compared to Clopiodgrel and aspirin, the combination of aspirin plus Ticagrelor has been shown to have some added benefit.
The key is to see the cardiologist! Let him/her decide.
bmj 2014;349:g6269
