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Ideas and Opinions |20 March 2007

Role of Clopidogrel in Managing Atherothrombotic Cardiovascular Disease

Shervin Eshaghian, MD; Sanjay Kaul, MD; Sameer Amin, MD; Prediman K. Shah, MD; George A. Diamond, MD

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
  • From the Cedars-Sinai Medical Center and the David Geffen School of Medicine, University of California, Los Angeles, California.

    Grant Support: None.

    Potential Financial Conflicts of Interest: None disclosed.

    Requests for Single Reprints: Sanjay Kaul, MD, Division of Cardiology, Room 5536, South Tower, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048; e-mail, kaul@cshs.org.

    Current Author Addresses: Drs. Eshaghian, Kaul, Amin, Shah, and Diamond: Division of Cardiology, Room 5536, South Tower, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048.

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Monotherapy with clopidogrel compared with aspirin
Clopidogrel is nominally superior to aspirin in reducing ischemic vascular events in high-risk patients.
Clopidogrel has improved gastrointestinal tolerance but causes an excess of rash, diarrhea, and adverse hematologic outcomes.
Combined therapy (clopidogrel plus aspirin) compared with monotherapy
Clopidogrel plus aspirin versus aspirin
Beneficial in high-risk patients, such as those with unstable angina/non–ST-elevation myocardial infarction (UA/ NSTEMI), ST-elevation myocardial infarction (STEMI), and stenting.
Long-term benefit is driven by reductions in nonfatal myocardial infarction, but there is little or no impact on death or stroke.
Major bleeding complications are increased.
Clopidogrel plus aspirin versus clopidogrel
No benefit in reducing ischemic stroke.
Major bleeding complications are increased.
Clopidogrel versus ticlopidine
No major difference in efficacy and safety has been reported in randomized trials; increased adverse hematologic events with ticlopidine have been reported in nonrandomized studies.
Ticlopidine is less expensive; clopidogrel has better tolerability and convenience (once-daily dosing).
Key issues regarding clopidogrel use in clinical practice
Duration of treatment
No long-term benefit but excess moderate bleeding risk in patients with stable cardiovascular disease; therefore, it is not recommended in such patients.
At least 1 month and up to 9 months in high-risk patients with UA/NSTEMI who are at low-risk for bleeding.
At least 1 month with fibrinolytic treatment in patients with STEMI; there are no direct studies in patients with primary percutaneous coronary intervention (PCI).
Up to 1 month with bare metal stents, longer treatment (>6 mo and perhaps longer) with drug-eluting stents in patients with PCI....
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Eshaghian S, Kaul S, Amin S, et al. Role of Clopidogrel in Managing Atherothrombotic Cardiovascular Disease. Ann Intern Med. 2007;146:434–441. doi: 10.7326/0003-4819-146-6-200703200-00008

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Published: Ann Intern Med. 2007;146(6):434-441.

DOI: 10.7326/0003-4819-146-6-200703200-00008

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2007 American College of Physicians
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