Key result
VASP-guided clopidogrel loading yields an absolute ~10% reduction in 1-month MACE vs. standard dosing.
Why the study?
Clopidogrel resistance contributes to ischemic recurrence after PCI, and adjusting clopidogrel dose based on VASP index may impact major adverse cardiac events.
Does adjusting the clopidogrel loading dose according to the VASP index reduce major adverse cardiac events in patients with clopidogrel resistance undergoing PCI?
RCT (n=162)
Yes
Does adjusting the clopidogrel loading dose according to the VASP index reduce major adverse cardiac events in patients with clopidogrel resistance undergoing PCI?
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Adjusting the loading dose of clopidogrel according to platelet monitoring with the [vasodilator-stimulated phosphoprotein] VASP assay is feasible, safe, and efficacious in reducing post-PCI major adverse cardiac events [MACE]”
“provocative and encouraging”
Individualized adjustment of clopidogrel loading doses using VASP index monitoring significantly reduces short-term major adverse cardiac events in patients demonstrating clopidogrel resistance after an initial 600-mg dose.
OBJECTIVES: This study evaluates the clinical impact of adjusting the loading dose of clopidogrel according to vasodilator-stimulated phosphoprotein (VASP) index in patients with clopidogrel resistance undergoing percutaneous coronary intervention (PCI). BACKGROUND: Clopidogrel resistance plays a key role in ischemic recurrence after PCI. In vitro tests of clopidogrel resistance can accurately predict major adverse cardiac events after PCI. METHODS: In this prospective, randomized, multicenter study, clopidogrel resistance was defined as a VASP index of more than 50% after a 600-mg loading dose. Patients with clopidogrel resistance undergoing coronary stenting were randomized to a control group or to the VASP-guided group, in which patients received additional bolus clopidogrel to decrease the VASP index below 50%. RESULTS: A total of 162 patients were included. The control (n = 84) and VASP-guided groups (n = 78) had similar demographic, clinical, and biological characteristics. In the VASP-guided group, dose adjustment was efficient in 67 patients (86%) and VASP index was significantly decreased (from 69.3 +/- 10 to 37.6 +/- 13.8; p < 0.001). Eight major adverse cardiac events (5%) were recorded during the 1-month follow-up, with a significantly lower rate in the VASP-guided group compared with the control group (0% vs. 10%; p = 0.007). There was no difference in the rate of major and minor bleeding (5% vs. 4%; p = 1). CONCLUSIONS: This is the first study to suggest that adjusting the clopidogrel loading dose according to platelet monitoring using the VASP index is safe and may significantly improve the clinical outcome after PCI in patients with clopidogrel resistance despite a first 600-mg loading dose.
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Bonello et al. (2008) conducted an RCT in Clopidogrel resistance undergoing percutaneous coronary intervention (PCI) (n=162). Adjusted clopidogrel loading dose according to VASP index vs. Control group was evaluated on Major adverse cardiac events (p=0.007). Adjusting the clopidogrel loading dose according to the VASP index significantly decreased the rate of major adverse cardiac events compared to the control group at 1 month (0% vs. 10%; p=0.007).
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