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- myocardial infarction
- platelet aggregation inhibitors
- ticlopidine
- aspirin
- anti-inflammatory agents (non-steroidal)
- adrenergic beta-antagonists
- metoprolol
Q In patients hospitalised within 24 hours of suspected acute myocardial infarction (AMI), does the addition of clopidogrel to aspirin and the early use of metoprolol improve outcomes?
Clinical impact ratings IM/Ambulatory care ★★★★★★★ Internal medicine ★★★★★★☆ Cardiology ★★★★★★★ Emergency medicine ★★★★★★☆
METHODS
Design
randomised placebo controlled trial with 2 × 2 factorial design (Clopidogrel and Metoprolol in Myocardial Infarction Trial [COMMIT]).
Allocation
concealed.*
Blinding
blinded {clinicians, patients, and outcome assessors}†.*
Follow up period
until first hospital discharge or 28 days.
Setting
1250 hospitals in China.
Patients
45 852 patients (mean age 61 y, 72% men) hospitalised within 24 hours (mean 10 h) of onset of symptoms of AMI, with ST elevation (87%), left bundle branch block (6%), or ST depression (7%) and no clear indication for or against the study medications. Those with moderate heart failure were eligible. Patients scheduled for primary percutaneous coronary intervention (PCI) and those with small likelihood of benefit or high risk for adverse effects were excluded.
Interventions
clopidogrel, 75 mg once daily (n = 22 961), or placebo (n = 22 891); all patients also received aspirin, 162 mg once daily. Intravenous (IV) metoprolol, 5 mg, up to 3 doses given over 2–3 minutes and spaced 2–3 minutes apart (provided heart rate >50 beats/min and systolic blood pressure >90 mm Hg), then oral metoprolol, 50 mg every 6 hours for 2 days, followed by oral controlled release metoprolol, 200 mg once daily (n = 22 929), or placebo (n = 22 923). 54% of patients also received fibrinolytic therapy.
Outcomes
clopidogrel study: composite end point (death, reinfarction, or stroke), all cause mortality, …
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