Heart Health
Over-The-Counter Aspirin is Best Choice for Most Consumers Needing Heart, Stroke Protection
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Apr 12, 2007 - 9:54:32 AM

Over-The-Counter Aspirin is Best Choice for Most Consumers Needing Heart, Stroke Protection

Clopidogrel (Plavix) plus aspirin is superior treatment for selected patients

(Washington D.C.) – For most people who need a blood-thinning drug to help prevent a first or repeat heart attack or stroke, aspirin is the drug of choice, according to the latest report from the Consumer Reports Best Buy Drugs® project (www.CRBestBuyDrugs.org).

Aspirin is one of four drugs in a class of medicines called antiplatelets. The other three are Aggrenox (a combination of aspirin and the drug dipyridamole), clopidogrel (Plavix), and ticlopidine (Ticlid).

The medicines decrease blood clotting, which evidence now shows is intimately tied to heart attack and stroke risk. As a result, the use of aspirin and other antiplatelets has skyrocketed in recent years.

“This report will help doctors and consumers clarify the choices when it comes to use of blood-thinning medicines,” said Steven Findlay, managing editor of Consumer Reports Best Buy Drugs. “The almost incredible advantage here is that tens of millions of people can benefit from taking a medicine – aspirin – that is among the least expensive available and does not require a prescription.”

The Consumers Union/Consumer Reports analysis – drawing on 39 studies that directly compared the drugs from over 4,000 published studies screened – evaluated the effectiveness, safety, and cost of the four drugs in varying clinical circumstances. Available free to consumers at the Best Buy Drugs Web site, as well as the Consumer Reports site at www.ConsumerReports.org/BBD_anticlotting, the report makes the following Best Buy treatment recommendations:

Aspirin – for people who have risk factors for heart attack and stroke – such as high blood pressure, smoking, diabetes, and/or high cholesterol – but who have not been diagnosed with heart disease or had a heart attack, stroke, or mini-stroke (also known as a transient ischemic attack, or TIA). Almost all adults with risk factors-alone are candidates for aspirin and do not need one of the other, more expensive antiplatelet medicines such as Plavix.

Aspirin – for people diagnosed with heart disease and so-called “stable” angina Clopidogrel (Plavix) – for people who have been diagnosed with heart disease, have stable angina but can not take aspirin

Aspirin + clopidogrel (Plavix) – for people diagnosed with “unstable” angina or acute coronary syndrome (ACS), have had a heart attack, or have had angioplasty and stent placement in the past year

Aggrenox – for people who have had a stroke or mini-stroke (TIA)

The report recommends that ticlopidine (Ticlid) not be prescribed at all since it poses some unique and dangerous risks and has no advantages over the other antiplatelet medicines.

In recommending aspirin plus clopidogrel (Plavix) for people who have had a heart attack and angioplasty with stent placement, the report acknowledges the strength of recent evidence indicating clear improved results for this combination treatment. Plavix was the seventh best-selling brand-name drug and the 10th most advertised drug, with $124 million spent in 2006 on ads aimed at consumers. Its generic, clopidogrel, was the 13th best-selling generic in the U.S. in 2006.

However, clopidogrel is no longer allowed to be marketed due to a court battle. The generic came on the market in early August 2006 after state antitrust officials rejected a patent settlement between the maker and distributor of Plavix (Bristol-Myers Squibb and Sanofi-Aventis) and a generic company (Apotex) that would have delayed the generic entry until 2011. A federal district court subsequently halted the sales of the generic in late August, but not before Apotex flooded the market with the generic.

Over the past eight months, most prescriptions filled for the drug have been for the generic (clopidogrel), which was 20 percent to 30 percent less expensive than Plavix at most pharmacies nationwide. However, supplies of the generic on pharmacy shelves are now running out and doctors will have to return to prescribing Plavix, and pharmacists to dispensing it.

“This is an unfortunate situation for consumers, who will now have to pay more for this drug because of a court battle,” Findlay says. “A return of the generic version of Plavix as soon as possible will be the best scenario for Americans.”

Both the Federal Trade Commission and the Department of Justice are investigating the arrangement that led to the rejected patent settlement.

The report discusses – in consumer-friendly language – the fast-moving changes in cardiology that impact the use of antiplatelets. Just in the past few months alone several major studies have underscored the effectiveness of these medicines and shed new light on when they are best applied, and when angioplasty and stents are needed.

Central to these developments is distinguishing between people who have so-called stable versus unstable angina (chest pain due to artery narrowing and/or blockage).

Stable angina is diagnosed in people whose chest pain predictably appears during exercise or emotional distress and typically goes away after a few minutes of rest. Unstable angina is diagnosed when chest pain and other symptoms start to occur with increasing frequency and severity, or when pain occurs when a person is at rest and inactive.

People with unstable angina are at much greater risk of heart attack. Indeed, unstable angina can mean that a heart attack is imminent because of a dangerously narrowed or completely blocked artery. Doctors also refer to people in this state as having “acute coronary syndrome” (ACS). ACS is considered a medical emergency requiring immediate treatment and possible hospitalization.

The report’s recommendations reflect an emerging medical consensus that people with stable angina should be treated initially with drugs only, including an antiplatelet (aspirin). A landmark study published in March shows that after five years people who had stable angina and were treated this way did just as well as those who underwent angioplasty (though angioplasty reduced their angina quicker).

People with unstable angina or ACS also need antiplatelets and other medicines but are also much more likely to need angioplasty or even bypass surgery.

“We hope the report promotes the use of aspirin and the other antiplatelets in people who need them,” Findlay said.

Of the 40 percent of American adults (85 million) who have heart disease or heart disease risk factors, somewhere between 40 and 60 percent are not taking an antiplatelet.

However, the report recommends that people talk with a doctor before starting to take a daily aspirin on their own. Long-term aspirin use carries serious risks of gastrointestinal and brain bleeding and the benefits must be weighed against the risks, especially for people who have had stomach bleeding or ulcers in the past.

The antiplatelet report is the 17th in a series helping consumers find effective and safe medicines that give them the most value for their health-care dollar. Other Best Buy Drugs reports compare drugs to treat depression, high blood pressure, heartburn, high cholesterol, asthma, allergies, migraines, insomnia, and overactive bladder.

Consumer Reports Best Buy Drugs combines a review of the scientific evidence on the effectiveness and safety of medicines with pricing information. Every report is peer-reviewed by medical experts. The project is independently administered by Consumers Union and Consumer Reports with support from the Engelberg Foundation, a private philanthropy, and the National Library of Medicine.

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