Q. I had a heart attack. My HMO sent me to a hospital 40 milles away. A stent was inserted and Plavix was prescribed for three months and I was to see a local cardiologist in 3 weeks.
The local cardiologist directed me to stop taking Plavix. Three months later I had another heart attack which became much more complicated. I was admitted to two different hospitals four different times within two weeks. The stent was replaced and I was advised to take Plavix for 12 months. What are the standards for taking Plavix?
A. We felt unprepared to answer your question about Plavix (clopidogrel) ourselves since this is a complex and somewhat controversial issue. To do you justice, we consulted two of the country’s leading cardiologists. They would prefer to remain anonymous, but they are without a doubt authorities in this field. Here are their comments:
CARDIOLOGIST # 1:
“The CURE Trial (NEJM 2001) showed a 20% reduction in recurrent MI [heart attack], death and stroke when given for 12 months after an acute MI.
“It’s appropriate therapy for this patient assuming there are no unusual bleeding risks.”
“It is hard to say whether stopping Plavix led to the second heart attack…but it is a reasonable question to ask.”
CARDIOLOGIST # 2
“Always hard to say much without seeing the patient to know all the factors
involved, but the general recommendation is dual anti platelet therapy for
at least 3 months, and in general one year for drug eluting stents,
although the data for this are equivocal.”
We followed this answer up with more questions:
So…does this mean that at one year and one day after a patient gets a drug eluting stent he should stop Plavix?
Plavix isn’t completely benign. Given that the data are equivocal…what kind of recommendations make
sense? Do you think we will we ever have some clarity on this rather crucial question?
CARDIOLOGIST # 2’S FOLLOW-UP ANSWERS:
“85% of major decisions lack high-level evidence. The trials are being done. Plavix isn’t benign but a thromboses [clogged] stent is a disaster.”
“How long to take a chronic treatment is a problem in every field and good trials of stopping are rarely done.”
“There are really good observational studies with conflicting results.”
“Stents are changing and the duration probably should change as a function of 2 factors: 1) stent type; 2) underlying risk of a new event (mostly determined by extent of CAD [coronary artery disease]).”
“For today’s DES [drug eluting stents] I would continue for one year and then assess; if all was stable, I had a good exercise tolerance, no symptoms and no multi vessel disease I’d stop at that point.”
“The trials are in process.”
Ultimately, the decision will depend upon your own cardiologist, but clearly this is a controversial topic and one that is in flux. Thanks for asking a very important question for which is there no perfect answer at this time.
You should be aware of some of the side effects associated with Plavix (clopidogrel). If you develop any symptoms while taking this drug please contact your MD promptly!
PLAVIX SIDE EFFECTS:
(special danger with NSAID pain relievers like ibuprofen or naproxen-GI bleeding!)
• Blood disorders
• Serious allergic reactions
• Skin rash (contact physician immediately!)