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Clopidogrel in Patients With Acute Coronary Syndromes: Learning From Clinical Practice—Reply

Clopidogrel in Patients With Acute Coronary Syndromes: Learning From Clinical Practice—Reply In reply We appreciate the interest and the comments by Ziegelstein regarding our article.1 Ziegelstein pointed out that the lack of long-term clopidogrel use among patients with NSTE ACS may be related to the fact that the guideline recommendation regarding use of clopidogrel after discharge is currently based on the results of only 1 clinical trial, the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial.2 Moreover, Ziegelstein found the results of the CURE trial itself not convincing, because the benefit of clopidogrel was partially counterbalanced by an increased bleeding risk. While we cannot say whether the low use of clopidogrel has occurred only after thoughtful and critical review of the evidence by community physicians, we believe that other factors may be at play. The use of several less controversial and expensive therapies such as β-blockers, statins, and angiotensin-converting enzyme inhibitors have lagged decades after the publication of evidence supporting their use and their incorporation into practice guidelines.3 Furthermore, careful studies have indicated that nonadherence to guideline recommendations rarely reflects a lack of physician consensus with the existing evidence.4 Rather, we suggest that other factors may play an equal or more critical role. Clinicians may be wary of adding additional long-term therapies to patients with ACS. Statin therapy took years to be accepted as a needed agent beyond aspirin and β-blockers, despite multiple trials clearly demonstrating incremental benefit.5 And now, clopidogrel similarly struggles to be the “next new agent” for secondary prevention, despite its demonstrated ability to reduce long-term risk for death, myocardial infarction, or stroke when added on top of standard therapies in the CURE and the Clopidogrel for the Reduction of Events During Observation (CREDO) trials.2,6 In addition, clopidogrel is costly and causes physicians to consider its economic impact on their patients. However, cost-effectiveness studies have defended the value of clopidogrel following both ACS and percutaneous coronary intervention.7,8 In the end, we agree with Ziegelstein that clinical trials and guidelines for all therapies should be carefully considered by clinicians before their acceptance and application to an individual patient. Quality improvement initiatives such as the CRUSADE initiative attempt to serve up this evidence for physicians to consider and compare their care practices with those of their peers across the country and ultimately provide a framework for discussing reasons for lack of adherence to guideline recommendations. Correspondence: Dr Tricoci, Duke Clinical Research Institute, 2400 Pratt St, Room 0311 Terrace Level, Durham, NC 27705 (trico001@dcri.duke.edu). References 1. Tricoci PRoe MTMulgund J et al. Clopidogrel to treat patients with non-ST-segment elevation acute coronary syndromes after hospital discharge. Arch Intern Med 2006;166806- 811PubMedGoogle ScholarCrossref 2. Yusuf SZhao FMehta SR et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001;345494- 502PubMedGoogle ScholarCrossref 3. Ma JStafford RS Quality of US outpatient care: temporal changes and racial/ethnic disparities. Arch Intern Med 2005;1651354- 1361PubMedGoogle ScholarCrossref 4. Cabana MDRand CSPowe NR et al. Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999;2821458- 1465PubMedGoogle ScholarCrossref 5. Fonarow GCFrench WJParsons LSSun HMalmgren JA Use of lipid-lowering medications at discharge in patients with acute myocardial infarction: data from the National Registry of Myocardial Infarction 3. Circulation 2001;10338- 44PubMedGoogle ScholarCrossref 6. Steinhubl SRBerger PBMann JT III et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002;2882411- 2420PubMedGoogle ScholarCrossref 7. Mahoney EMMehta SYuan Y et al. Long-term cost-effectiveness of early and sustained clopidogrel therapy for up to 1 year in patients undergoing percutaneous coronary intervention after presenting with acute coronary syndromes without ST-segment elevation. Am Heart J 2006;151219- 227PubMedGoogle ScholarCrossref 8. Cowper PAUdayakumar KSketch JMichael HPeterson ED Economic effects of prolonged clopidogrel therapy after percutaneous coronary intervention. J Am Coll Cardiol 2005;45369- 376PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Clopidogrel in Patients With Acute Coronary Syndromes: Learning From Clinical Practice—Reply

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Publisher
American Medical Association
Copyright
Copyright © 2006 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.166.20.2293
Publisher site
See Article on Publisher Site

Abstract

In reply We appreciate the interest and the comments by Ziegelstein regarding our article.1 Ziegelstein pointed out that the lack of long-term clopidogrel use among patients with NSTE ACS may be related to the fact that the guideline recommendation regarding use of clopidogrel after discharge is currently based on the results of only 1 clinical trial, the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial.2 Moreover, Ziegelstein found the results of the CURE trial itself not convincing, because the benefit of clopidogrel was partially counterbalanced by an increased bleeding risk. While we cannot say whether the low use of clopidogrel has occurred only after thoughtful and critical review of the evidence by community physicians, we believe that other factors may be at play. The use of several less controversial and expensive therapies such as β-blockers, statins, and angiotensin-converting enzyme inhibitors have lagged decades after the publication of evidence supporting their use and their incorporation into practice guidelines.3 Furthermore, careful studies have indicated that nonadherence to guideline recommendations rarely reflects a lack of physician consensus with the existing evidence.4 Rather, we suggest that other factors may play an equal or more critical role. Clinicians may be wary of adding additional long-term therapies to patients with ACS. Statin therapy took years to be accepted as a needed agent beyond aspirin and β-blockers, despite multiple trials clearly demonstrating incremental benefit.5 And now, clopidogrel similarly struggles to be the “next new agent” for secondary prevention, despite its demonstrated ability to reduce long-term risk for death, myocardial infarction, or stroke when added on top of standard therapies in the CURE and the Clopidogrel for the Reduction of Events During Observation (CREDO) trials.2,6 In addition, clopidogrel is costly and causes physicians to consider its economic impact on their patients. However, cost-effectiveness studies have defended the value of clopidogrel following both ACS and percutaneous coronary intervention.7,8 In the end, we agree with Ziegelstein that clinical trials and guidelines for all therapies should be carefully considered by clinicians before their acceptance and application to an individual patient. Quality improvement initiatives such as the CRUSADE initiative attempt to serve up this evidence for physicians to consider and compare their care practices with those of their peers across the country and ultimately provide a framework for discussing reasons for lack of adherence to guideline recommendations. Correspondence: Dr Tricoci, Duke Clinical Research Institute, 2400 Pratt St, Room 0311 Terrace Level, Durham, NC 27705 (trico001@dcri.duke.edu). References 1. Tricoci PRoe MTMulgund J et al. Clopidogrel to treat patients with non-ST-segment elevation acute coronary syndromes after hospital discharge. Arch Intern Med 2006;166806- 811PubMedGoogle ScholarCrossref 2. Yusuf SZhao FMehta SR et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001;345494- 502PubMedGoogle ScholarCrossref 3. Ma JStafford RS Quality of US outpatient care: temporal changes and racial/ethnic disparities. Arch Intern Med 2005;1651354- 1361PubMedGoogle ScholarCrossref 4. Cabana MDRand CSPowe NR et al. Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999;2821458- 1465PubMedGoogle ScholarCrossref 5. Fonarow GCFrench WJParsons LSSun HMalmgren JA Use of lipid-lowering medications at discharge in patients with acute myocardial infarction: data from the National Registry of Myocardial Infarction 3. Circulation 2001;10338- 44PubMedGoogle ScholarCrossref 6. Steinhubl SRBerger PBMann JT III et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002;2882411- 2420PubMedGoogle ScholarCrossref 7. Mahoney EMMehta SYuan Y et al. Long-term cost-effectiveness of early and sustained clopidogrel therapy for up to 1 year in patients undergoing percutaneous coronary intervention after presenting with acute coronary syndromes without ST-segment elevation. Am Heart J 2006;151219- 227PubMedGoogle ScholarCrossref 8. Cowper PAUdayakumar KSketch JMichael HPeterson ED Economic effects of prolonged clopidogrel therapy after percutaneous coronary intervention. J Am Coll Cardiol 2005;45369- 376PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Nov 13, 2006

Keywords: acute coronary syndromes,clopidogrel

References