Over 500,000 percutaneous coronary interventions (PCIs)—coronary angioplasties—with stent placement are performed each year in the United States. During these procedures, a balloon-tipped catheter is inserted into the coronary artery, and the balloon is inflated to open up the blocked artery. A stent, which is a hollow mesh tube, is placed in the artery to keep it open.
Doctors prescribe the combination therapy of aspirin and the anti-clotting drug, clopidogrel, for 1 month after PCI to prevent further heart problems. However, prolonging clopidogrel therapy up to 1 year after PCI is economically attractive, particularly in patients at high risk for heart attack after PCI, according to findings from a recent study. The study was supported by the Agency for Healthcare Research and Quality (HS10548) through the Centers for Education and Research on Therapeutics (CERTs) program.
A research team at the Duke University CERT used decision analysis to compare the outcomes and cost of discontinuing clopidogrel treatment at 1 month after PCI with prolonging treatment up to 1 year after PCI. They based rates of major events after PCI (heart attack, death, and repeat revascularization) on 3,976 PCI patients who were treated between January 1999 and December 2001 at the Duke Medical Center and received no more than 1 month of post-PCI clopidogrel. The effect of prolonged clopidogrel therapy on event rates (heart attack, bleeding, repeat revascularization, death) was based on data from the Clopidogrel for the Reduction of Events During Observation (CREDO) trial.
Extending clopidogrel therapy from 1 month to 1 year after PCI cost $879 per patient ($775 for high-risk patients) and reduced the risk of heart attack by 2.6 percent (by 3.5 percent in high-risk patients from 8 percent to 4.5 percent). Assuming heart attack decreases life expectancy by 2 years, prolonged therapy would cost $15,696 per year of life saved ($10,333 for high-risk patients). The economic attractiveness of therapy varied with patient baseline risk, the effect of prolonged therapy on heart attack risk, and the price of clopidogrel (an expensive $3.22 per day).
See "Economic effects of prolonged clopidogrel therapy after percutaneous coronary intervention," by Patricia A. Cowper, Ph.D., Krishna Udayakumar, M.D., M.B.A., Michael H. Sketch, Jr., M.D., and Eric D. Peterson, M.D., M.P.H., F.A.C.C., in the February 1, 2005, Journal of the American College of Cardiology 45(3), pp. 369-376.
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