Clopidogrel in non-ST-segment elevation acute coronary syndromes

Platelets play a central role in the pathophysiology of arterial thrombosis in patients with acute coronary syndrome (ACS). Aspirin is superior to placebo in preventing mortality and ischemic events in patients with ACS. Clopidogrel, when added to aspirin and given daily for up to 1 year, reduces cardiovascular death, myocardial infarction and stroke by 20% in patients presenting with ACS. The benefits of long term therapy with clopidogrel are present in those patients treated medically, with percutaneous coronary intervention and with CABG surgery. There is a higher risk of bleeding with clopidogrel, but this risk may be lowered with use of lower doses of aspirin (<100 mg daily). The benefits of clopidogrel in those patients undergoing an early invasive strategy may be enhanced by increasing the loading dose to 600 mg, followed by 150 mg daily for one week, then 75 mg daily. This hypothesis is being tested in the CURRENT OASIS 7 trial involving 14000 patients with ACS undergoing an early invasive strategy with intent for PCI within 24 hours, who will be randomized to this higher dose regimen of clopidogrel versus the standard dose regimen of 300 mg loading dose followed by 75 mg daily.