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CLINICAL RESEARCH: ACUTE CORONARY SYNDROMES

Long-term cost-effectiveness of clopidogrel given for up to one year in patients with acute coronary syndromes without ST-segment elevation

William S. Weintraub, MD, FACC^*,*, Elizabeth M. Mahoney, ScD, Andre Lamy, MD, Steven Culler, PhD^*, Yong Yuan, PhD, Jaime Caro, MD^||, Sylvie Gabriel, MD^¶, Salim Yusuf, MD, FACC CURE Study Investigators

^* Emory University, Atlanta, Georgia
New England Research Institutes, Watertown, Massachusetts
McMaster University, Hamilton, Ontario, Canada
Bristol-Myers Squibb, Princeton, New Jersey
^|| Caro Research Institute, Concord, Massachusetts
^¶ Sanofi-Synthelabo, Paris, France

Manuscript received July 26, 2004; revised manuscript received November 13, 2004, accepted November 16, 2004.

^* Reprint requests and correspondence: Dr. William S. Weintraub, Emory Center for Outcomes Research, 1256 Briarcliff Road, Suite 1N, Atlanta, Georgia 30306 (Email: wweintr{at}emory.edu).

OBJECTIVES: We sought to evaluate the long-term cost-effectiveness of clopidogrel for up to one year after an acute coronary syndrome (ACS) without ST-segment elevation.

BACKGROUND: The efficacy of platelet inhibition with clopidogrel for up to one year after ACS was demonstrated in the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial, a randomized trial of 12,562 patients in 28 countries that was conducted between 1998 and 2000. Patients were given clopidogrel (300-mg load followed by 75 mg/day) versus placebo, both in addition to aspirin, for a mean of nine months.

METHODS: We used patient-level clinical outcomes and resource use from the CURE trial and estimates of life expectancy gains as a result of the prevention of the clinical events of death, stroke, and myocardial infarction on the basis of data from external sources.

RESULTS: Excluding clopidogrel costs, average costs of hospitalizations alone were $325 less for the clopidogrel arm (95% confidence interval –$722 to $45) using diagnosis-related group-based Medicare reimbursement rates. When including clopidogrel costs ($766 greater for the clopidogrel arm), average total costs were $442 higher for the clopidogrel arm (95% confidence interval $62 to $820). The incremental cost-effectiveness ratio (ICER) on the basis of the Framingham Heart Study was $6,318 per life-year gained (LYG) with clopidogrel, with 94% of bootstrap-derived ICER estimates <$50,000/LYG; based on Saskatchewan, the ICER was $6,475/LYG with 98% of estimates <$50,000.

CONCLUSIONS: Platelet inhibition with clopidogrel in patients for up to one year after presentation with an acute coronary syndrome is both effective and cost-effective.

Abbreviations and Acronyms   ACS = acute coronary syndrome   CURE = Clopidogrel in Unstable angina to prevent Recurrent Events trial   DRG = diagnosis-related group   ICER = incremental cost-effectiveness ratio   MI = myocardial infarction   LOS = length of stay   LYG = life-year gained   PCI = percutaneous coronary intervention   QALYs = quality-adjusted life-years

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