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Clopidogrel Bolus is Inferior to Sustained Clopidogrel Pretreatment in Patients Undergoing Carotid Artery Stent
Adnan I Qureshi1, Wei Huang1, Iryna Lobanova1
1Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, Missouri, USA.
Insights
A single clopidogrel bolus before carotid artery stenting (CAS) is linked to increased risks of stroke and death compared to sustained clopidogrel pretreatment. Sustained pretreatment offers better long-term outcomes for patients undergoing CAS.
Area of Science:
- Cardiovascular medicine
- Interventional cardiology
- Pharmacology
Background:
- Carotid artery stenting (CAS) is a procedure to prevent stroke.
- Antiplatelet therapy is crucial for patients undergoing CAS.
- Clopidogrel is a commonly used antiplatelet medication.
Purpose of the Study:
- To compare the safety and efficacy of a clopidogrel bolus versus sustained clopidogrel pretreatment before CAS.
- To evaluate the impact of different clopidogrel regimens on periprocedural and long-term adverse events.
Main Methods:
- A comparative study analyzing data from the Carotid Revascularization Endarterectomy versus Stenting Trial.
- Patients were divided into two groups: clopidogrel bolus (≥4 hours before CAS) and sustained clopidogrel pretreatment (≥48 hours before CAS).
- Primary endpoint included stroke, myocardial infarction, or death within 4 years, analyzed using Cox proportional hazards models.
Main Results:
- Patients receiving a clopidogrel bolus had significantly higher rates of periprocedural stroke (7.3% vs. 3.4%) and the primary endpoint (11.3% vs. 5.9%).
- The adjusted hazard ratio for the primary endpoint was 1.9 in favor of sustained pretreatment.
- Mean primary endpoint-free survival was shorter in the clopidogrel bolus group (7.0 years) compared to the sustained pretreatment group (8.9 years).
Conclusions:
- Clopidogrel bolus before CAS is associated with increased adverse outcomes compared to sustained pretreatment.
- Sustained clopidogrel pretreatment appears to be a safer and more effective strategy for patients undergoing CAS.
- The findings suggest that clopidogrel bolus alone may not be a sufficient alternative to sustained pretreatment.
Background:
Clopidogrel bolus is an option used before carotid artery stent (CAS) placement when sustained clopidogrel pretreatment is not used.
Objective:
To compare the effect of clopidogrel bolus (450 mg administered ≥4 hours) with sustained clopidogrel pretreatment (48 hours or greater) before CAS among patients recruited in the Carotid Revascularization Endarterectomy versus Stenting Trial.
Methods:
We compared the rates of primary end point (either any stroke, myocardial infarction, or death during the periprocedural period or any ipsilateral stroke within 4 years) between patients who received clopidogrel bolus and those who received sustained clopidogrel pretreatment using Cox proportional hazards analysis after adjusting for age, sex, symptomatic status, and initial severity of stenosis (≥70% vs <70%) over 4 years.
Results:
The rate of periprocedural stroke (7.3% vs 3.4%, P = .03) and primary end point (11.3% vs 5.9%, P = .02) was significantly higher among patients who received clopidogrel bolus. The risk of primary end point was significantly higher in patients who received clopidogrel bolus (hazards ratio 1.9, 95% CI 1.1-3.4, P = .02) after adjusting for potential confounders. The overall mean (±standard deviation) primary end point-free survival based on Kaplan-Meier analysis was 7.0 ± 0.2 years for patients who received clopidogrel bolus and 8.9 ± 0.1 years for those who received sustained clopidogrel pretreatment (log-rank test P = .011).
Conclusion:
Clopidogrel bolus was associated with higher rates of adverse outcomes compared with sustained clopidogrel pretreatment in patients who underwent CAS. Therefore, clopidogrel bolus may not be equivalent to sustained clopidogrel pretreatment.
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