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Antiplatelet medications like aspirin, which reduce blood-coagulating platelets, lower by 30 percent the rate of another heart attack, stroke, or death from vascular causes among patients who have previously suffered from these coronary heart disease (CHD) problems. Clopidogrel, another antiplatelet medication, also reduces the relative risk of these CHD problems in patients with prior cardiovascular disease, but it has much higher daily costs than aspirin.
Use of aspirin for the secondary prevention of CHD is cost effective, but use of the more expensive clopidogrel is currently unattractive, unless restricted to patients who are ineligible for aspirin, according to a study that was supported in part by the Agency for Healthcare Research and Quality (HS06258). Researchers in Switzerland, the Netherlands, and in the United States at Harvard and the University of California, San Francisco, carried out the study. They used a computer simulation of the U.S. population with CHD over age 35. They estimated the cost-effectiveness of four strategies to reduce the rate of cardiovascular events in these patients over the period 2003-2027. The strategies studied were aspirin for all eligible patients (not allergic or intolerant to aspirin), aspirin for all eligible patients plus clopidogrel for patients who were ineligible for aspirin, clopidogrel for all patients, and the combination of aspirin and clopidogrel for all patients.
The extension of aspirin therapy from the current levels of use to all eligible patients for 25 years would have an estimated cost-effectiveness ratio of about $11,000 per quality-adjusted life year (QALY) gained. The addition of clopidogrel for the 5 percent of patients who are ineligible for aspirin would cost about $31,000 per QALY gained. Clopidogrel alone in all patients or in routine combination with aspirin had an incremental cost of more than $100,000 per QALY gained and remained financially unattractive across a wide range of reasonable assumptions. Except in highest risk patients, clopidogrel became relatively cost effective (less than $50,000 per QALY gained) only if its cost was reduced substantially.
See "Cost effectiveness of aspirin, clopidogrel, or both for secondary prevention of coronary heart disease," by Jean-Michel Gaspoz, M.D., Pamela G. Coxson, Ph.D., Paula A. Goldman, M.P.H., and others, in the June 6, 2002 New England Journal of Medicine 346(23), pp. 1800-1806.
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