Peter Eriksson, MD, PhD
Potential Financial Conflicts of Interest: None disclosed.
Eriksson P. Cost-Effectiveness of Clopidogrel plus Aspirin versus Aspirin Alone. Ann Intern Med. 2005;143:464. doi: 10.7326/0003-4819-143-6-200509200-00014
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Published: Ann Intern Med. 2005;143(6):464.
TO THE EDITOR:
Although I read Schleinitz and Heidenreich's article (1) with interest, I am concerned about their conclusion. They stated, “In patients with high-risk acute coronary syndromes, 1 year of therapy with clopidogrel plus aspirin results in greater life expectancy than aspirin alone, at a cost within the traditional limits of cost-effectiveness.” There are evidently better ways to be cost-effective.
In the CURE trial (2), patients with an acute coronary syndrome without ST-segment elevation received clopidogrel or placebo, in addition to aspirin, for a mean of 9 months. Nonetheless, most ischemic events (cardiovascular death, myocardial infarction, or stroke) occurred early, and there was basically no difference in the rates of events between the clopidogrel and placebo groups after the first 3 months. Approximately 85% of the total benefit achieved after 1 year with clopidogrel was observed already by 3 months (2, 3). The excess risk for bleeding with dual antiplatelet therapy is constant, however, which unfavorably changes the risk–benefit ratio when clopidogrel is given over the long term (4). If clopidogrel is used for 3 months rather than 1 year, most of the benefit of the drug would be achieved and bleeding hazards as well as costs of therapy would be reduced by approximately 75%. This would be a judicious compromise among clinical efficiency, side effects, and economy.
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