CLOpidogrel & Metoprolol in Myocardial Infarction Trial (COMMIT)

Introduction

45,853 patients in China presenting within 24 hours of suspected myocardial infarction.

All patients received standard treatment, including aspirin.

1/2 of the patients received fibrinolytic therapy.

96% with confirmed myocardial infarction

87% with ST-segment elevation on EKG

24% with moderate heart failure on entry

Study funded by manufacturer of both drugs

Treatment groups:

• Oral clopidogrel 75 mg immediately, then daily
• metoprolol 5-15 mg IV bolus, then infusion titrated to heart rate > 50/min, systolic blood pressure > 90 mm Hg then 200 mg PO QD
• both clopidogrel & metoprolol
• neither

Endpoints:

• death, reinfarction, cardiac arrest, stroke
• endpoints recorded at hospital discharge or at 28 days whichever came 1st

Results:

• patients who received clopidogrel vs those that did not with lower composite outcome of death, reinfarction or stroke 9.2% vs 10.1% & all-cause mortality 7.5% vs 8.1%
  • no significant increase in bleeding with clopidgrel
• patients who received metoprolol vs those that did not had fewer reinfarctions (2.0 vs 2.5%), fewer episodes of ventricular fibrillation (2.5% vs 3.0%) & more episodes of cardiogenic shock (5.0% vs 3.9%),
  • fewer deaths from arrhythmias (1.7% vs 2.2%)
  • more deaths from cardiogenic shock (2.2% vs 1.7%)
  • no change in all-cause mortality
• most of the excess risk occurred on the 1st day
• most of the benefit emerged after day 2

More general terms

• clinical trial