To the Editor:
I have read with great interest the editorial regarding the clinical repercussions of the CURE study.1,2 I believe it was an excellent description of the study and the questions it poses, but I would like to make some observations on the article.
In the first place, my attention it drawn to the extremely conservative management of the patients included in the study, which could have an influence on the benefits which were observed. In spite of the fact that one-third of the patients were categorized as high risk and another third as intermediate risk, only 21.8% underwent revascularization during admission (13.8% with angioplasty and 8% with surgery). I do not know whether managing the patients at risk in accordance with current recommendations3 (use of glucoprotein IIb/IIIa antagonists and revascularization) would have provided the same benefit as that observed.
In the second place, the convenience of prolonged treatment, as is mentioned in some of the author´s opinions, should be clarified. In the low risk group more precise data is needed regarding the cost to efficacy ratio: 62 patients had to be treated in order to avoid an event; this treatment is costly and has a certain risk of hemorrhage. On the other hand, the results from the PCI-CURE study4 demonstrated that the benefit obtained in patients undergoing percutaneous revascularization occurred during the pre-angioplasty period and in the 30 days post-angioplasty. After 30 days, there were no significant differences in the presence of cardiovascular mortality and myocardial infarct (3.6% placebo group and 3.1% in the clopidogrel group). In these patients, therefore treatment prior to intervention and 30 days following could be sufficient.
In the third place, my attention is drawn to the tone of the article purported to be an editorial in the Revista Española de Cardiología. For example, the following paragraph is a literal quote: «The final conclusion of the CURE study is that clopidogrel significantly reduces the risk of cardiovascular death, myocardial infarct, and cerebrovascular accident, a benefit which more than compensates for excessive bleeding.» The authors of the study expressed these conclusions: «The platelet aggregation inhibitor clopidogrel has important benefits in patients with acute coronary syndromes without ST-segment elevation. Nevertheless, the risk of significant hemorrhage was increased in those treated with clopidogrel.»
Finally, I would like to say that it would be a good idea is those authors with a commercial involvement would indicate what kind of relationship they have or had with the pharmaceutical industry that selling these products.