clopidogrel added to aspirin

[star21]

just wanted to know what your views are for clopidogrel to be added alongside aspirin in patients with Atrial Fibrilation, any hopsitals currently doing this if so is it working, does it reall decrease risks of vacular events in these patients or cause greater side effects and higher costs....

thanks

[star21]

sorry about typos my keyboard is really weak

[bobbin]

just wanted to know what your views are for clopidogrel to be added alongside aspirin in patients with Atrial Fibrilation, any hopsitals currently doing this if so is it working, does it reall decrease risks of vacular events in these patients or cause greater side effects and higher costs....

thanks

AFAIK, this is not normally recommended. The risk of bleeding is quite high, it's expensive and it's less effective than warfarin. Warfarin is recommended for most patients. Aspirin alone only for very low-risk patients. Aspirin + clopidogrel might be suitable for patients considered to be at high risk of stroke if there are definite contraindications to warfarin.

[Pillbox]

This would not be used unless warfarin was CI then only after careful consideration and discussion bearing in mind an absolute risk reduction of just over 2%. Outcomes are so much worse, both CV events and bleeds, that one trial which looked at AF patients with high stroke risk was stopped early. ACTIVE-W.

CURE, MATCH and CHARISMA trials all showed long term use of aspirin and clopidogrel benefit was outweighed by risk of a major bleed. The limit of 12 months following NSTEMI is the balance (in that condition) when risk overcomes benefit. also bear in mind that with current practice survivability of an MI ( I know you asked about AF but it is I think relevant) is higher than survival post major GI bleed.

The ACTIVE trial was a classic, number of events prevented was just outweighed by adverse events provoked so it was just a bit worse than doing nothing. But the figures could be manipulated to just show the opposite.

ACTIVE A was promoted as showing a benefit. “Consider 1,000 patients treated for three years. If you did that, you would prevent 28 strokes — 17 of which would be disabling or fatal — and six MIs at a cost of 20 major bleeds"
But there were 251 major bleeding events in the clopidogrel/aspirin group and 162 in the aspirin only group. The NNH is 42 over 3.6 years (not calculated by the trialists) given all that AND that currently clopidogrel is not licensed for use in patients with AF who are at a high risk of vascular events and who are unable for various reasons to take warfarin, I would find it hard to justify to a patient an off licence indication with a nearly in balance risk/benefit ratio.
NEJM -- Effect of Clopidogrel Added to Aspirin in Patients with Atrial Fibrillation