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To the Editor: Dr Steinhubl and colleagues¹ found that the benefits of clopidogrel were consistent regardless of patients' characteristics. In this trial, many patients also received glycoprotein IIb/IIIa inhibitors if the treating physician felt that this additional therapy was indicated. One recent study, however, has found that IIb/IIIa inhibition may have selective benefits for diabetic patients with acute coronory symptoms, but not mortality advantage for nondiabetic patients.² Similarly, in the CURE trial, patients with non-ST elevation who were at highest risk also had the greatest absolute benefit of this treatment.^2-3 Thus, a subgroup analysis using the Thrombolysis in Myocardial Infarction (TIMI) risk score would provide further information whether clopidogrel therapy might be even more effective in high- and intermediate-risk patients.

Attila Dirkali, MD; Victor A. Umans, MD, PhD
Medical Center Alkmaar
Alkmaar, the Netherlands

1. Steinhubl SR, Berger PB, Mann JT 3rd, Fry ET, DeLago A, Wilmer C, Topol EJ. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA. 2002;288:2411-2420. FREE FULL TEXT 2. Roffi M, Chew DP, Mukherjee D, Bhatt DL, White JA, Heeschen C, Hamm CW, Moliterno DJ, Califf RM, White HD, Kleiman NS, Theroux P, Topol EJ. Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes. Circulation. 2001;104:2767-2771. FREE FULL TEXT 3. Budaj A, Yusuf S, Mehta SR, Fox KA, Tognoni G, Zhao F, Chrolavicius S, Hunt D, Keltai M, Franzosi MG. Benefit of clopidogrel in patients with acute coronary syndromes without ST-segment elevation in various risk groups. Circulation. 2002;106:1622-1626. FREE FULL TEXT 4. Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494-502. FREE FULL TEXT

Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.

JAMA. 2003;289:1926.

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