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Clopidogrel Adds Benefit to Aspirin for ACS Patients
Clopidogrel, a thienopyridine derivative, inhibits platelet aggregation and, thereby, improves outcomes for patients undergoing percutaneous transluminal coronary angioplasty with stenting (Eur Heart J 2000; 21:2033). Because thrombosis plays such an important role in acute coronary syndrome (ACS), these investigators conducted the industry-sponsored, randomized, double-blind CURE trial: They compared clopidogrel (300-mg oral loading dose, then 75 mg daily) plus aspirin (dose range, 75 to 325 mg daily) with placebo plus aspirin in 12,562 ACS patients without ST-segment elevation (mean treatment duration, 9 months). All patients had been hospitalized with ACS within 24 hours of symptom onset at 482 centers in 28 countries over 22 months.
The primary outcomes were (A) cardiovascular death, nonfatal MI, or stroke and (B) outcome A or refractory ischemia. Compared with the placebo group, the clopidogrel group had significantly lower rates of outcome A (9.3 percent vs. 11.4 percent) and outcome B (16.5 percent vs. 18.8 percent). Among endpoint components, the rate of MI showed the most marked between-groups difference (5.2 percent vs. 6.7 percent).
Revascularization rates were similar between the groups. Differences in outcome A were consistent across a spectrum of subgroups. Major bleeding complications were significantly more common among clopidogrel (3.7 percent) than among placebo (2.7 percent) recipients.
Comment: The CURE trial presents strong evidence for combining clopidogrel plus aspirin rather than using aspirin alone to treat ACS effectively. This benefit, requiring treatment of about 50 patients for 9 months to prevent 1 adverse event, is relatively attractive but probably quite costly; however, some of the added cost may be offset by lower hospitalization rates.
— HM Krumholz
Published in Journal Watch Cardiology September 28, 2001
Citation(s):
The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001 Aug 16 345 494-502.
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