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Comparative effectiveness of clopidogrel in medically managed patients with unstable angina and non-ST-segment elevation myocardial infarction.
J Am Coll Cardiol. 2014 Jun 03; 63(21):2249-57.JACC

Abstract

OBJECTIVES

This study sought to examine the effectiveness of clopidogrel in real-world, medically managed patients with unstable angina (UA) or non-ST-segment elevation myocardial infarction (NSTEMI).

BACKGROUND

Although clinical trials have demonstrated the efficacy of clopidogrel to reduce cardiovascular (CV) morbidity and mortality in medically managed patients with UA or NSTEMI, the effectiveness of clopidogrel in actual clinical practice is less certain.

METHODS

A retrospective cohort study was conducted of Kaiser Permanente Northern California members without known coronary artery disease or prior clopidogrel use who presented with UA or NSTEMI between 2003 and 2008 and were medically managed (i.e., no percutaneous coronary intervention or coronary artery bypass grafting during the index hospitalization or within 7 days post-discharge). Over 2 years of follow-up, we measured the association between clopidogrel use and all-cause mortality, hospital stay for MI, and a composite endpoint of death or MI using propensity-matched multivariable Cox analyses.

RESULTS

We identified 16,365 patients with incident UA (35%) or NSTEMI (65%); 36% of these patients were prescribed clopidogrel within 7 days of discharge. In 8,562 propensity score-matched patients, clopidogrel users had lower rates of all-cause mortality (8.3% vs. 13.0%; p < 0.01; adjusted hazard ratio [HR]: 0.63; 95% confidence interval [CI]: 0.54 to 0.72) and the composite of death or MI (13.5% vs. 17.4%; p < 0.01; HR: 0.74, CI: 0.66 to 0.84), but not MI alone (6.7% vs. 7.2%; p = 0.30; HR: 0.93, CI: 0.78 to 1.11), compared with nonusers of clopidogrel. The association between clopidogrel use and the composite of death or MI was significant only among patients presenting with NSTEMI (HR: 0.67; CI: 0.59 to 0.76; pint < 0.01), not among those presenting with UA (HR: 1.25; CI: 0.94 to 1.67).

CONCLUSIONS

In a large, community-based cohort of patients who were medically managed after UA/NSTEMI, clopidogrel use was associated with a lower risk of death and MI, particularly among patients with NSTEMI.

Authors+Show Affiliations

Division of Research, Kaiser Permanente Northern California, Oakland, California; Stanford University School of Medicine, Stanford, California. Electronic address: Matthew.D.Solomon@kp.org.Division of Research, Kaiser Permanente Northern California, Oakland, California; Stanford University School of Medicine, Stanford, California; University of California, San Francisco, San Francisco, California.Stanford University School of Medicine, Stanford, California.Stanford University School of Medicine, Stanford, California.Division of Research, Kaiser Permanente Northern California, Oakland, California.University of California, San Francisco, San Francisco, California; San Francisco General Hospital, San Francisco, California.Stanford University School of Medicine, Stanford, California.Stanford University School of Medicine, Stanford, California.

Pub Type(s)

Comparative Study
Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

24703914

Citation

Solomon, Matthew D., et al. "Comparative Effectiveness of Clopidogrel in Medically Managed Patients With Unstable Angina and non-ST-segment Elevation Myocardial Infarction." Journal of the American College of Cardiology, vol. 63, no. 21, 2014, pp. 2249-57.
Solomon MD, Go AS, Shilane D, et al. Comparative effectiveness of clopidogrel in medically managed patients with unstable angina and non-ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2014;63(21):2249-57.
Solomon, M. D., Go, A. S., Shilane, D., Boothroyd, D. B., Leong, T. K., Kazi, D. S., Chang, T. I., & Hlatky, M. A. (2014). Comparative effectiveness of clopidogrel in medically managed patients with unstable angina and non-ST-segment elevation myocardial infarction. Journal of the American College of Cardiology, 63(21), 2249-57. https://doi.org/10.1016/j.jacc.2014.02.586
Solomon MD, et al. Comparative Effectiveness of Clopidogrel in Medically Managed Patients With Unstable Angina and non-ST-segment Elevation Myocardial Infarction. J Am Coll Cardiol. 2014 Jun 3;63(21):2249-57. PubMed PMID: 24703914.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Comparative effectiveness of clopidogrel in medically managed patients with unstable angina and non-ST-segment elevation myocardial infarction. AU - Solomon,Matthew D, AU - Go,Alan S, AU - Shilane,David, AU - Boothroyd,Derek B, AU - Leong,Thomas K, AU - Kazi,Dhruv S, AU - Chang,Tara I, AU - Hlatky,Mark A, Y1 - 2014/04/02/ PY - 2013/09/26/received PY - 2014/01/24/revised PY - 2014/02/05/accepted PY - 2014/4/8/entrez PY - 2014/4/8/pubmed PY - 2014/8/5/medline KW - acute coronary syndrome(s) KW - clopidogrel KW - outcomes SP - 2249 EP - 57 JF - Journal of the American College of Cardiology JO - J Am Coll Cardiol VL - 63 IS - 21 N2 - OBJECTIVES: This study sought to examine the effectiveness of clopidogrel in real-world, medically managed patients with unstable angina (UA) or non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND: Although clinical trials have demonstrated the efficacy of clopidogrel to reduce cardiovascular (CV) morbidity and mortality in medically managed patients with UA or NSTEMI, the effectiveness of clopidogrel in actual clinical practice is less certain. METHODS: A retrospective cohort study was conducted of Kaiser Permanente Northern California members without known coronary artery disease or prior clopidogrel use who presented with UA or NSTEMI between 2003 and 2008 and were medically managed (i.e., no percutaneous coronary intervention or coronary artery bypass grafting during the index hospitalization or within 7 days post-discharge). Over 2 years of follow-up, we measured the association between clopidogrel use and all-cause mortality, hospital stay for MI, and a composite endpoint of death or MI using propensity-matched multivariable Cox analyses. RESULTS: We identified 16,365 patients with incident UA (35%) or NSTEMI (65%); 36% of these patients were prescribed clopidogrel within 7 days of discharge. In 8,562 propensity score-matched patients, clopidogrel users had lower rates of all-cause mortality (8.3% vs. 13.0%; p < 0.01; adjusted hazard ratio [HR]: 0.63; 95% confidence interval [CI]: 0.54 to 0.72) and the composite of death or MI (13.5% vs. 17.4%; p < 0.01; HR: 0.74, CI: 0.66 to 0.84), but not MI alone (6.7% vs. 7.2%; p = 0.30; HR: 0.93, CI: 0.78 to 1.11), compared with nonusers of clopidogrel. The association between clopidogrel use and the composite of death or MI was significant only among patients presenting with NSTEMI (HR: 0.67; CI: 0.59 to 0.76; pint < 0.01), not among those presenting with UA (HR: 1.25; CI: 0.94 to 1.67). CONCLUSIONS: In a large, community-based cohort of patients who were medically managed after UA/NSTEMI, clopidogrel use was associated with a lower risk of death and MI, particularly among patients with NSTEMI. SN - 1558-3597 UR - https://www.unboundmedicine.com/medline/citation/24703914/Comparative_effectiveness_of_clopidogrel_in_medically_managed_patients_with_unstable_angina_and_non_ST_segment_elevation_myocardial_infarction_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0735-1097(14)01654-4 DB - PRIME DP - Unbound Medicine ER -