Durham, NC - The use of long-term clopidogrel in patients with non-ST-elevation ACS is disappointingly low, especially in those patients not treated with PCI, new data suggest [1].

The analysis, from the US CRUSADE registry, published in the April 10, 2006 issue of the Archives of Internal Medicine, shows that most non-ST-elevation ACS patients not treated with PCI did not receive clopidogrel at hospital discharge.

"Our data suggest that the message of the benefit of clopidogrel among non-PCI ACS patients has not been received clearly enough," lead author Dr Pierluigi Tricoci (Duke University School of Medicine, Durham, NC) commented to heartwire.

In the paper, Tricoci et al note that the CURE trial showed a 20% relative risk reduction in the composite of cardiovascular death, MI, or stroke when clopidogrel was given on top of aspirin for nine to 12 months after an episode of non-ST-elevation ACS and that the treatment effect of clopidogrel was consistent across all treatment strategies, including medical treatment, PCI, and CABG. These results were incorporated into the ACC/AHA guidelines in March 2002, with a class I recommendation for clopidogrel at discharge for all non-ST-elevation ACS patients.

The current analysis of the CRUSADE registry included 61 052 patients with high-risk non-ST-elevation ACS (defined as the presence of positive cardiac markers and/or ischemic ST-segment changes) from January 2002 through December 2003. Of these, just over half—34 319 patients (56.2%)—received clopidogrel when they were discharged from the hospital.

Tricoci et al report that patients who underwent PCI tended to be discharged on clopidogrel, but those who had not received a PCI were far less likely to be given the drug. Although clopidogrel prescription at discharge increased in all groups from 2002 to 2003, by late 2003, 96.3% of patients who underwent PCI received clopidogrel at discharge, compared with just 42.8% of patients who did not undergo cardiac catheterization. The group least likely to receive discharge clopidogrel were those patients who had undergone CABG, with only 23.5% of these patients sent home on the drug.

In an interview with heartwire, Tricoci explained that clopidogrel was used most in patients given a stent because of fears of thrombosis. But he added that about the rest of the ACS population there seems to be a lack of knowledge of the benefits of clopidogrel. He suggested that the very low number of CABG patients sent home on clopidogrel was probably due to confusion about interpreting the guidelines. "The guidelines recommend that clopidogrel is stopped five days before CABG, but they do not stipulate when it should be restarted. But there are no data to show an increase in bleeding risk in CABG patients with clopidogrel use on discharge, so these patients should also be sent home on the drug. I think the guidelines could be made clearer on this point," he said.

Tricoci also pointed out that another barrier to the prescription of clopidogrel on discharge was cost, as patients with private insurance were more likely to receive the drug than those without private insurance.

In addition, because prescribing clopidogrel at discharge was associated with higher uptake of other guideline recommendations, this practice may be a marker of hospitals with a greater commitment to quality improvement and better systems in place to ensure consistent, evidence-based discharge care, the authors say.