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To the Editor: The meta‐analysis by Hernandez et al1 showed that the reduction of death or non‐fatal myocardial infarction with IIb/IIIa inhibitors in patients with an acute coronary syndrome (ACS) was independent of patient age. The trials included were performed before widespread administration of clopidogrel in ACS.
Clopidogrel has been shown to be beneficial in ACS; its administration is a class I recommendation.2 Glycoprotein IIb/IIIa inhibition is a class I recommendation only in patients with planned percutaneous coronary intervention (PCI) in the absence of clopidogrel, but is a class IIa recommendation in patients already treated with clopidogrel.2
An analysis of the National Registry of Myocardial Infarction‐4 suggested that routinely giving a glycoprotein IIb/IIIa inhibitor to patients with a non‐ST‐elevation ACS treated with clopidogrel might not be justified, especially if PCI were not performed.3 This may be particularly true in elderly patients, since virtually all studies indicate that elderly patients are more likely to bleed than younger patients; bleeding has been shown to be an independent predictor of mortality in both ACS and PCI patients.4
An analysis of the ISAR‐REACT 2 trial showed that abciximab did not reduce the 30‐day incidence of death or any other component of major adverse cardiac events in older patients with a non‐ST‐elevation ACS treated with clopidogrel; in fact, it seemed to be harmful.5 We are currently analysing the relationship between age and outcome in three other ISAR studies.
In conclusion, while we applaud the excellent analysis of the authors, we caution that the results of their meta‐analysis may not be generalisable to all patients with ACS, particularly the elderly pretreated with clopidogrel.
Competing interests: None declared.