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ClOpidogrel and Metoprolol in Myocardial Infarction Trial |
REACTIONS FROM INDEPENDENT HEART SPECIALISTS TO
COMMIT/CCS-2
Comment by Professor Jean-Pierre Bassand,
Besançon, France, immediate Past-President of the European
Society of Cardiology (ESC).
This is landmark study for several reasons. With
45,852 patients it is the second largest ever carried out in
cardiology. It was organised, run and completed in China thanks
to an exemplary collaboration between the Chinese cardiology
community and Oxford University CTSU.
The findings provide evidence that this dual
platelet inhibition (clopidogrel plus aspirin) results in a
significant reduction of the risk of death and major adverse
cardiac events in patients with acute myocardial infarction,
without excess risk of bleeding. For the first time since GUSTO
(published in 1993), a significant improvement in outcome is
achieved thanks to improved pharmacological treatment in ST
elevation MI. The fact that, in this trial, early use of
metoprolol leads to significant reduction in ventricular
fibrillation and recurrence of MI at the expense of an increased
risk of cardiogenic shock has to be interpreted with
caution.
These two major findings may well prompt us to
launch a revision of the European Society of Cardiology's
Guidelines on the management of this disease.
Dr Christopher Cannon, Professor of Medicine,
Harvard Medical School, USA.
Speaking of the findings on metoprolol:
"In this era of increased attention on drug safety, this landmark trial shows that a class of drugs widely thought to be safe and highly effective can have adverse effects in some patients, while being very beneficial in others. It reaffirms the need for doctors to balance the risks and benefits of all medical therapies in individual patients."
"In this era of increased attention on drug safety, this landmark trial shows that a class of drugs widely thought to be safe and highly effective can have adverse effects in some patients, while being very beneficial in others. It reaffirms the need for doctors to balance the risks and benefits of all medical therapies in individual patients."
Dr Michael Gent, former Professor of Clinical
Epidemiology, McMaster University, Hamilton, Ontario, Canada, and
principal investigator in the first large trial of clopidogrel
(CAPRIE).
Speaking of the findings on clopidogrel:
"This is a terrific result. Is this an advance in the treatment of heart attack? Absolutely. The research team has clearly demonstrated a very important benefit. There is no doubt now that a combination of aspirin and clopidogrel should become standard practice straightaway in the emergency treatment of acute MI unless there is a particular reason why not in an individual patient. The one concern - that the combination of aspirin and clopidogrel might cause bleeding - has been shown not to be a problem and it is also clear from the uniformly consistent results that the benefits have to be cost effective."
"This is a terrific result. Is this an advance in the treatment of heart attack? Absolutely. The research team has clearly demonstrated a very important benefit. There is no doubt now that a combination of aspirin and clopidogrel should become standard practice straightaway in the emergency treatment of acute MI unless there is a particular reason why not in an individual patient. The one concern - that the combination of aspirin and clopidogrel might cause bleeding - has been shown not to be a problem and it is also clear from the uniformly consistent results that the benefits have to be cost effective."
Dr Salim Yusuf, Professor of Medicine, Director
of Population Health Research Institute, McMaster University,
Hamilton, Ontario, Canada.
"The results of COMMIT emphasise yet again the
importance of large well-conducted randomised trials. Although
the impact of Clopidogrel appears modest, it is clinically
important and likely highly cost efficient, especially since it
has few side effects. The COMMIT trial also clarifies the
appropriate patient selection for the use of beta-blockers. Both
results are of significant importance for the clinician looking
after patients with heart attacks."