The worry about clopidogrel "nonresponsiveness": identification and treatment in the post-percutaneous coronary intervention patient.

Sinai Center for Thrombosis Research, Baltimore, Maryland.
JACC. Cardiovascular Interventions (Impact Factor: 1.07). 11/2009; 2(11):1102-4. DOI: 10.1016/j.jcin.2009.09.005
Source: PubMed
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    ABSTRACT: Background: The CYP2C19 genotype is a predictor of adverse cardiovascular events in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) treated with clopidogrel. Objective: We aimed to evaluate the cost-effectiveness of a CYP2C19*2 genotype-guided strategy of antiplatelet therapy in ACS patients undergoing PCI, compared to two "no testing" strategies (empiric clopidogrel or prasugrel). Methods: We developed a Markov model to compare three strategies. The model captured adverse cardiovascular events and antiplatelet-related complications. Costs were expressed in 2010 US dollars and estimated using diagnosis-related group codes and Medicare reimbursement rates. The net wholesale price for prasugrel was estimated as $5.45/day. A generic estimate for clopidogrel of $1.00/day was used, and genetic testing was assumed to cost $500. Results: Base case analyses demonstrated little difference between treatment strategies. The genetic testing-guided strategy yielded the most QALYs and was the least costly. Over 15 months, total costs were $18 lower with a gain of 0.004 QALY in the genotype-guided strategy compared to empiric clopidogrel, and $899 lower with a gain of 0.0005 QALY compared to empiric prasugrel. The strongest predictor of the preferred strategy was the relative risk of thrombotic events in carriers compared to wild-type individuals treated with clopidogrel. Above a 47% increased risk, a genotype-guided strategy was the dominant strategy. Above a clopidogrel cost of $3.96 per day, genetic testing was no longer dominant but remained cost-effective. Conclusions: Among ACS patients undergoing PCI, a genotype-guided strategy yields similar outcomes to empiric approaches to treatment, but is marginally less costly and more effective. © 2012 International Society on Thrombosis and Haemostasis.
    Journal of Thrombosis and Haemostasis 11/2012; · 6.08 Impact Factor

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