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Published at www.nejm.org December 22, 2008 (10.1056/NEJMoa0808227)

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ABSTRACT

Background Pharmacogenetic determinants of the response of patients to clopidogrel contribute to variability in the biologic antiplatelet activity of the drug. The effect of these determinants on clinical outcomes after an acute myocardial infarction is unknown.

Methods We consecutively enrolled 2208 patients presenting with an acute myocardial infarction in a nationwide French registry and receiving clopidogrel therapy. We then assessed the relation of allelic variants of genes modulating clopidogrel absorption (ABCB1), metabolic activation (CYP3A5 and CYP2C19), and biologic activity (P2RY12 and ITGB3) to the risk of death from any cause, nonfatal stroke, or myocardial infarction during 1 year of follow-up.

Results Death occurred in 225 patients, and nonfatal myocardial infarction or stroke in 94 patients, during the follow-up period. None of the selected single-nucleotide polymorphisms (SNPs) in CYP3A5, P2RY12, or ITGB3 were associated with a risk of an adverse outcome. Patients with two variant alleles of ABCB1 (TT at nucleotide 3435) had a higher rate of cardiovascular events at 1 year than those with the ABCB1 wild-type genotype (CC at nucleotide 3435) (15.5% vs. 10.7%; adjusted hazard ratio, 1.72; 95% confidence interval [CI], 1.20 to 2.47). Patients carrying any two CYP2C19 loss-of-function alleles (*2, *3, *4, or *5), had a higher event rate than patients with none (21.5% vs. 13.3%; adjusted hazard ratio, 1.98; 95% CI, 1.10 to 3.58). Among the 1535 patients who underwent percutaneous coronary intervention during hospitalization, the rate of cardiovascular events among patients with two CYP2C19 loss-of-function alleles was 3.58 times the rate among those with none (95% CI, 1.71 to 7.51).

Conclusions Among patients with an acute myocardial infarction who were receiving clopidogrel, those carrying CYP2C19 loss-of-function alleles had a higher rate of subsequent cardiovascular events than those who were not. This effect was particularly marked among the patients undergoing percutaneous coronary intervention. (ClinicalTrials.gov number, NCT00673036 [ClinicalTrials.gov] .)

Source Information

From Assistance Publique–Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, and Université Pierre et Marie Curie (UPMC) Paris 06 (T.S., L.Q., E.D.); AP-HP, Hôpital Bicètre, Université Paris Sud 11 (C.V., L.B.); INSERM, Unite 720 (M.M.-K.); AP-HP, Hôpital Bichat; INSERM, Unite 698; and Université Paris 07 (P.G.S.); and AP-HP, Hôpital Européen Georges Pompidou, Université Rene Descartes Paris 05 (N.D.) — all in Paris; Centre Hospitalier Universitaire Besançon, Besançon (N.M.); and INSERM, Unite 558, Toulouse (J.F.) — all in France.

Drs. Danchin and Becquemont contributed equally to this article.

This article (10.1056/NEJMoa0808227) was published at NEJM.org on December 22, 2008. It will appear in the January 22 issue of the Journal.

Address reprint requests to Dr. Simon at the Department of Pharmacology, UPMC, 27 Rue Chaligny, 75012 Paris, France, or at tabassome.simon{at}sat.aphp.fr.

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