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Summaries for Patients |15 February 2005

Is It Cost-Effective To Treat High-Risk Cardiac Patients with Clopidogrel plus Aspirin as Opposed to Aspirin Alone?

Article, Author, and Disclosure Information

What is the problem and what is known about it so far?

Heart attacks and strokes are often caused by blood clots that clog arteries. Blood is made up of a liquid (serum) in which many different particles (formed elements) are suspended. Formed elements include such things as red cells, white cells, and platelets. Clot formation depends largely on activities of the platelets. Platelets can respond to external signals from other parts of the body by changing their surface characteristics, such as their ability to stick to each other, forming a clot. Doctors have found that they can prevent platelets from becoming sticky by giving certain types of medication, including aspirin and clopidogrel. Researchers have recently shown that when both of these drugs are given together, they are more effective than aspirin alone in preventing heart attack, stroke, or cardiovascular death in high-risk patients. The trouble is that clopidogrel is very expensive and it is not certain that the cost of the combination can be justified.

Why did the researchers do this particular study?

To find out if it was cost-effective to treat high-risk cardiac patients with clopidogrel plus aspirin as opposed to aspirin alone.

Who was studied?

Instead of studying actual patients, the researchers used computers to see what would have happened to a simulated (imaginary) group of patients who had certain characteristics in which they were interested.

How was the study done?

The researchers calculated the costs and clinical results of treating a 64-year-old patient with clopidogrel plus aspirin for 1 year followed by aspirin alone or with aspirin alone over the patient's lifetime. They then calculated what the results would have been for older or younger patients. Cost calculations included medication, the cost of caring for heart attacks or strokes, and the cost of treating any potential complications of taking the medications (such as severe bleeding).

What did the researchers find?

On average, patients treated with clopidogrel plus aspirin would have lived about 1 month longer than those treated with aspirin alone, but some would have developed bleeding complications that would have worsened the quality of their lives. Treating all eligible patients with clopidogrel plus aspirin would have cost $15 400 per extra year (adjusted for quality of life) compared with aspirin alone. Each additional month of therapy added slightly to life expectancy and cost slightly more. Adding 1 year of combined therapy to 250 000 high-risk Americans would have led to a total gain of 25 500 quality-adjusted years of life at a cost to society of $392 million.

What are the limitations of the study?

The analysis is only as strong as the studies on which the risk estimates were based.

What are the implications of the study?

Combined therapy with clopidogrel and aspirin, as opposed to aspirin alone, increases average life expectancy in high-risk patients at a cost comparable to that of other effective treatments that are generally judged acceptable by society.

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2005 American College of Physicians

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