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Early ambulance initiation versus in-hospital initiation of high dose clopidogrel in ST-segment elevation myocardial
S Postma, J-H E Dambrink, J P Ottervanger
1A. W. J. van 't Hof, MD, PhD, FESC, Isala hospital, Department of Cardiology, Dokter Van Heesweg 2, 8025 AB Zwolle, The Netherlands, Tel.: +31 38 424 2374, Fax: +31 38 424 3222,
Insights
Administering high-dose (HD) clopidogrel in ambulances for ST-Segment Elevation Myocardial Infarction (STEMI) patients did not improve initial vessel patency. However, early HD clopidogrel significantly reduced recurrent myocardial infarctions at 30 days and one year.
Area of Science:
- Cardiology
- Emergency Medicine
- Pharmacology
Background:
- Pre-hospital diagnosis of ST-Segment Elevation Myocardial Infarction (STEMI) allows early administration of anti-platelet and anti-thrombotic agents.
- The optimal timing for initiating high-dose (HD) clopidogrel (600 mg) in STEMI patients remains under investigation, particularly comparing pre-hospital versus in-hospital administration.
- Evidence is needed to determine if ambulance-initiated HD clopidogrel improves infarct-related vessel (IRV) patency and clinical outcomes.
Purpose of the Study:
- To compare the effects of ambulance versus in-hospital initiation of HD clopidogrel on initial IRV patency.
- To evaluate the impact of pre-hospital HD clopidogrel administration on clinical outcomes in STEMI patients.
- To assess the association between early HD clopidogrel and recurrent myocardial infarctions, mortality, and major adverse cardiovascular events (MACE).
Main Methods:
- A single-centre prospective cohort study included 2,475 STEMI patients from 2001 to 2009.
- Patients were divided into two groups: in-hospital HD clopidogrel initiation (2001-June 2006) and ambulance HD clopidogrel initiation (July 2006-2009).
- Outcomes assessed included initial IRV patency (TIMI-2/3 flow pre-PCI), post-PCI flow, recurrent MI, bleeding, mortality, and MACE.
Main Results:
- Ambulance HD clopidogrel was not independently associated with improved initial IRV patency (TIMI-2/3 flow pre-PCI: OR 1.18, 95% CI 0.96-1.44).
- Patients receiving ambulance HD clopidogrel experienced fewer recurrent myocardial infarctions at 30 days (HR 0.45, 95% CI 0.22-0.93) and one year (HR 0.45, 95% CI 0.25-0.80).
- No significant differences were observed in post-PCI flow, major bleeding, mortality, or MACE between the groups.
Conclusions:
- Early in-ambulance initiation of HD clopidogrel in STEMI patients did not improve initial IRV patency or overall clinical outcomes.
- However, pre-hospital administration of HD clopidogrel demonstrated a significant reduction in recurrent myocardial infarctions.
- The findings suggest a net clinical benefit for early ambulance administration of HD clopidogrel due to the reduction in recurrent MI.
Abstract:
Pre-hospital infarct diagnosis gives the opportunity to start anti-platelet and anti-thrombotic agents before arrival at the PCI centre. However, more evidence is necessary to demonstrate whether high dose (HD) clopidogrel (600 mg) administered in the ambulance is associated with improved initial patency of the infarct related vessel (IRV) and/or clinical outcome compared to in-hospital initiation of HD clopidogrel. From 2001 until 2009 all consecutive ST-Segment Elevation Myocardial Infarction (STEMI) patients who underwent pre-hospital diagnosis and therapy in the ambulance were prospectively included in our single-centre cohort study. We compared initial patency of the IRV and clinical outcome in patients treated from 2001 until June 2006 (in-hospital HD clopidogrel) with patients treated from July 2006 until 2009 (ambulance HD clopidogrel). A total of 2,475 patients with STEMI were registered; of these 1,110 (44.8%) received in-hospital HD clopidogrel and 1,365 (55.2%) received ambulance HD clopidogrel. Ambulance HD clopidogrel was not independently associated with initial patency (TIMI-2/3-flow pre-PCI (odds ratio: 1.18, 95% confidence interval [CI] 0.96-1.44); however, it was associated with fewer recurrent myocardial infarctions at 30 days (hazard ratio [HR]: 0.45, 95% CI 0.22-0.93) and at one year (HR: 0.45, 95% CI 0.25-0.80). No difference in TIMI 2/3 flow post-PCI, major bleeding, mortality, MACE - and the combination of mortality and recurrent myocardial infarction at 30-days and at one year was present between the two groups. In conclusion, early in-ambulance as compared to in-hospital initiation of HD clopidogrel in STEMI patients did not improve initial patency of the IRV or clinical outcome, except for a reduction of recurrent myocardial infarction. Therefore, early administration of HD clopidogrel seems to have net clinical benefit for these patients.
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