Figure 2

(A) Survival curves for the primary outcome (cardiovascular death, nonfatal myocardial infarction, or stroke) in randomized trial [1]comparing clopidogrel to placebo following an acute coronary syndrome. (B) Survival curves for the primary outcome (cardiovascular death, nonfatal myocardial infarction, or stroke) in randomized trial [39] comparing clopidogrel to placebo following PCI. (C) Survival curves for the primary end point (cardiovascular death, myocardial infarction, or stroke) in randomized trial [40] comparing clopidogrel to placebo in patients with clinically evident stable cardiovascular disease or multiple risk factors stable cardiac patients. (D) Survival curves for primary outcome (mortality, non-fatal MI and target vessel revascularization) from an observational study [28] comparing PCI patients discharged on clopidogrel plus proton pump inhibitor (PPI) and clopidogrel alone. (E) Survival curves for the primary end point (death acute coronary syndrome) from an observational study [11] comparing ACS patients discharged on clopidogrel plus proton pump inhibitor (PPI) and clopidogrel alone. The randomized trials following an ACS or PCI (Figures 2A and 2B) show that the benefit of clopidogrel is obtained early (see red arrow at 3 months) with no or little additional benefit accrued thereafter (see blue arrow at 9 months). The lack of long term benefit in stable patients was confirmed in another randomized trial (Figure 2C). This is contrasted with the results of observational studies (Figures 2D and 2E) where there appears to be no increased risk with PPIs in the short term and the differences arise in the long term where the benefits of clopidogrel have not been demonstrated.