Herbert L. Fred, MD,
Editor, Correspondence Section
Circulation Editorial Office.
St Luke's Episcopal Hospital/Texas Heart Institute
Room B524 (MC1-267)
Letter to the Editor: Clopidogrel in Acute Coronary Syndromes.
Can the cost-effectiveness improve?.
Accepted for publication:
The usefulness
of clopidogrel and aspirin in acute coronary syndromes (CURE trial) was
clear from the beginning, and confirmed again in the new report from Salim Yusuf et. al. (1). The actual question is: could the
cost-effectiveness still be improved?.
I propose the
combination of Aspirin and Clopidogrel during the
first 30 days. Beyond 30 days, these medications could be given on alternate
days, one day Aspirin and the other day Clopidogrel.
That would reduce the cost, probably not affecting the efficacy and maybe
reducing the risk of life-threatening bleeds.
With this
approach, the main effect is reached in the first 30 days (4.3% vs. 5.4%), when
one needs to treat 91 patients to prevent one event. Beyond 30 days, the events
rise only 0.9% in total (5.2% vs. 6.3%), the relative risk reduction remains 18%,
and the absolute risk reduction is then only 0.16%, resulting in a Number
Needed to Treat of 625 to prevent an event. It is also
important to remember that the effect of Aspirin is irreversible, so that it is
active on the day off, and the new, not affected platelets, would be then
inhibited by Clopidogrel.
This strategy
could be very useful for the patients (and doctors) with limited economic
resources. These approach could also be useful in
cases of resistance to Aspirin.
Enrique
Sánchez-Delgado, MD
Medical
Director
Hospital
Metropolitano
Managua,
Nicaragua
1.- Yusuf S, Mehta SR, Zhao F et al. Early and Late Effects of Clopidogrel in
Patients With Acute Coronary Syndromes. Circulation 2003
107: 966 – 972.
Dear Dr. Sanchez-Delgado,
You raise an important issue and I hope Circulation will publish your paper.
Kind regards,
Salim Yusuf, D.Phil, FRCPC
Professor of Medicine
Director, Division of Cardiology
Director, Population Health Research Institute
McMaster University
Thu, 6 Mar 2003 12:17:22 -0500