Cheap drug clopidogrel may cut heart attack and stroke risk more than aspirin, review finds

A major international review has found that clopidogrel, an inexpensive antiplatelet drug, reduces the risk of heart attack, stroke or death by an additional 14 percent compared with aspirin for patients with coronary artery disease (CAD).

The global consortium of researchers, which includes investigators from Imperial College London, reported the findings in The Lancet and presented them at the European Society of Cardiology congress in Madrid. The authors said clopidogrel “offers superior protection” and argued there is a strong case for making it the preferred antiplatelet option in clinical practice. The medication costs less than 4 pence a day in the United Kingdom.

Coronary artery disease, also called coronary heart disease, is the most commonly diagnosed form of heart disease in the UK and affects an estimated 2.3 million people. The condition arises when arteries that supply the heart become narrowed by a build-up of atheroma, a fatty material within the artery walls, which can lead to chest pain, heart attacks and other serious complications. Patients with CAD are commonly advised to take a daily low-dose aspirin to inhibit platelets and reduce the risk of clot-related events.

The new review compared outcomes in patients taking aspirin with those taking clopidogrel, another platelet inhibitor that has been used in particular clinical settings for many years. Investigators reported that switching from aspirin to clopidogrel led to the additional 14 percent reduction in combined outcomes of heart attack, stroke or death. The researchers framed their conclusion as evidence that clopidogrel provides superior protection for people with established coronary artery disease.

The analysis was described by its authors as a major synthesis of available trial data. Details on the specific trials included, participant numbers and subgroup findings were published in The Lancet paper and discussed at the ESC meeting. The study’s authors said the magnitude of benefit, together with the low cost of clopidogrel, supports reconsideration of routine prescribing decisions for secondary prevention in CAD.

Clinicians and guideline authorities will need to review the full evidence, weigh potential benefits against known risks and consider individual patient factors before recommending a broad change in practice. Antiplatelet drugs can have differing safety profiles and effectiveness in particular patient groups, and established guidance often reflects trial settings, concomitant therapies and procedural factors.

The researchers called for the findings to inform clinical guidance and for conversations between patients and doctors about the most appropriate antiplatelet strategy for secondary prevention of cardiovascular events. Further appraisal by professional societies and regulators will determine whether and how practice changes are adopted.