EXPERT ANALYSIS FROM THE ANNUAL INTERNAL MEDICINE PROGRAM

ESTES PARK, COLO. (FRONTLINE MEDICAL NEWS) – Clopidogrel is vastly underutilized in real-world medical management of patients with unstable angina or non–ST-segment elevation MI who don’t undergo coronary revascularization, Dr. Mel L. Anderson said at a conference on internal medicine sponsored by the University of Colorado.

Such patients fall under the umbrella of the so-called CURE indication for clopidogrel, named for the landmark Clopidogrel in Unstable Angina to Prevent Recurrent Events trial. CURE showed that adding clopidogrel to aspirin for an average of 9 months in patients with acute coronary syndrome without ST-segment elevation reduced the major adverse cardiovascular event rate from 11.4% to 9.3% (N Engl J Med. 2001;345[7]:494-502).

Clinical practice has changed enormously since CURE was published in 2001, so a group of investigators decided to see if discharging medically managed ACS patients on clopidogrel is still beneficial in the contemporary setting. They conducted a retrospective observational cohort study of 16,345 Kaiser Permanente Northern California patients with unstable angina or NSTEMI managed medically without percutaneous coronary intervention or coronary artery bypass graft, of whom only 36% were discharged on clopidogrel.

“It’s disappointing that fully two-thirds of patients did not get clopidogrel when they had an indication for it,” commented Dr. Anderson, chief of the hospital medicine section at the Denver VA Medical Center and an internist at the university.

Two-year all-cause mortality was 8.3% in the clopidogrel users, compared with 13% in propensity-matched controls not on clopidogrel, for an adjusted 37% relative risk reduction in favor of the antiplatelet agent (J Am Coll Cardiol. 2014 Jun 3;63[21]:2249-57).

“That’s a number-needed-to-treat of 20. It’s really quite a robust benefit for a drug that’s now generic and has a well-established safety profile,” Dr. Anderson continued.

The 2-year composite outcome of death or MI occurred in 13.5% of the clopidogrel group and 17.4% of controls, for a number-needed-to-treat of about 25. Clopidogrel’s benefit in terms of this composite endpoint achieved significance only among the 65% of participants with NSTEMI, not those with unstable angina.

“Don’t forget the CURE indication for clopidogrel,” the hospitalist concluded.

bjancin@frontlinemedcom.com

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