SciELO - Scientific Electronic Library Online

vol.99 issue6Hydration with sodium bicarbonate does not prevent contrast nephropathy: a multicenter clinical trialCoronary tomography for predicting adverse events in patients with suspected coronary disease author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand




Related links


Arquivos Brasileiros de Cardiologia

Print version ISSN 0066-782X

Arq. Bras. Cardiol. vol.99 no.6 São Paulo Dec. 2012  Epub Nov 27, 2012 

Resistance to clopidogrel: prevalence and associate variables



Fabrício Braga da SilvaI,II; Gustavo Luiz Gouvêa de Almeida JuniorI; Augusto NenoI; José KezenI; Milena SpeltaI; Alessandra GodomiczerI; Renato VillelaI; Bruno HellmuthI; Sergio Salles XavierI; Roberto Hugo da Costa LinsI

ICasa de Saúde São José, Rio de Janeiro
IIUniversidade Federal do Rio de Janeiro, RJ – Brazil

Mailing Address




BACKGROUND: The dual antiplatelet therapy with acetylsalicylic acid (ASA) and clopidogrel is the cornerstone of treatment for patients undergoing angioplasty with coronary stent implantation. However, some of these patients, despite the use of aspirin and clopidogrel, are not effectively anti-aggregated, a phenomenon known as resistance to antiplatelet agents. Its prevalence, as well as the conditions associated with it, is unknown in our country.
OBJECTIVE: To determine the prevalence of clopidogrel resistance, as well as variables associated with it.
METHODS: Patients admitted for elective angioplasty in chronic use of ASA and clopidogrel between January 2007 and January 2010 were studied. One hour after the procedure, platelet aggregation was measured using optical aggregometry with adenosine diphosphate 5 mmoles / l as agonist. At that moment, in a cross-sectional cohort, we determined the prevalence of clopidogrel resistance, defined as the value of platelet aggregation > 43% and a logistic regression model to the variables associated with it.
RESULTS: A total of 205 patients were analyzed (66.4 ± 11 years, 61.5% males). The prevalence of clopidogrel resistance was 38.5% (95% CI: 31.9 - 45.2%). Blood glucose (OR = 1.014; 95%CI: 1.004 - 1.023), previous myocardial infarction (OR = 2.320; 95%CI: 1.1103 - 4.892) and therapeutic response to ASA (OR = 1.057; 95%CI: 1.017 - 1.099) were the variables independently associated with clopidogrel resistance.
CONCLUSION: The prevalence of clopidogrel resistance was high. Glycemia, acute myocardial infarction and response to ASA were variables associated with it. A better understanding of this phenomenon is necessary considering the new antiplatelet aggregant agents. (Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)

Keywords: Platelet aggregation inhibitors; drug resistance; stents; coronary disease; angioplasty, balloon, coronary.




Dual antiplatelet therapy with aspirin and thienopyridines is a cornerstone in the treatment of patients undergoing coronary stent implantation1. Although it was the drug initially used in combination with aspirin, ticlopidine2 was quickly replaced by clopidogrel due to its better safety and tolerability profile3. Thus, currently, in spite of new antiplatelet agents, aspirin (81 to 300 mg/day)4 and clopidogrel (75 mg/day) is the most widely used regimen after coronary stent implantation.

For some years, it has been known that the antiaggregant response of clopidogrel varies individually according to a number of factors such as genetics4, drug interactions5,6 and clinical conditions such as diabetes7. The incapacity of clopidogrel to inhibit platelet aggregation measured at the laboratory is known as clopidogrel resistance8. Regardless of the reasons for resistance, the prognostic impact of this condition has been shown in four meta-analyses9-12.

Despite the prognostic importance and growing scientific interest, according to our knowledge, there are no national publications that have described the occurrence of clopidogrel resistance.

The objective of this study is to determine the prevalence and conditions related to this phenomenon in patients undergoing elective coronary angioplasty with stent implantation, pretreated with aspirin and clopidogrel.

Material and Methods

This was a cross-sectional retrospective cohort study of patients admitted for elective angioplasty in the period between January 2007 and January 2010. Inclusion criteria were use of aspirin and clopidogrel for a period > 5 days (self-reported), hospitalization on the day of angioplasty, angiographic success1 and platelet aggregation measurement in the first hour after angioplasty. Patients using oral anticoagulants or any other antiaggregant drugs, those using glycoprotein IIB/IIIA inhibitors during angioplasty, those with platelet count <100,000 cells/mm3 and hematocrit < 30% were excluded.

As part of an institutional protocol, patients within the first hour after angioplasty were submitted to blood sampling for assessment of platelet aggregation, blood glucose, hematocrit, platelets, and creatinine levels. Platelet function was quantified by the optical aggregometry method in platelet-rich plasma (PRP) using the four-channel aggregometer Chronolog ® 470VS (Chronolog, Havertown, PA, USA). This method is still currently the most widely used in studies of clopidogrel resistance, and in spite of more recent assessment methods of platelet function, still remains the gold standard13. Adenosine diphosphate (ADP) was used as agonist to measure the therapeutic effect of clopidogrel at a concentration of 5 mmoles/L (Chronolog, Havertown, PA, USA). The pre-analytical and analytical phases followed all international recommendations for measuring platelet aggregation (PA)14.

Individuals with PA value > 43% were considered resistant to clopidogrel15. The following variables were analyzed: a) clinical-demographic: age, sex, ethnicity, comorbidities (hypertension, diabetes mellitus, dyslipidemia, smoking or former smoking, chronic obstructive pulmonary disease, prior acute myocardial infarction (AMI), prior cerebrovascular accident (CVA), prior coronary angioplasty (CA), prior myocardial revascularization (CABG) and chronic renal failure requiring dialysis, body mass index (BMI), medications (proton pump inhibitors, statins and calcium channel blockers); b) interventionist: number of approached vessels, approached vessels, number of implanted stents, overall stent length and procedure duration; c) laboratory: therapeutic response to aspirin measured by optical aggregometry using arachidonic acid as agonist at a concentration of 0.5 mg/mL (Helena Platelet Aggregation System, Helena Laboratories Corp., Beaumont, TX, USA), glycemia, hematocrit, platelet count and creatinine clearance. Aspirin resistance was determined by a value > 20%.

The use of omeprazole and lipophilic statins (simvastatin and atorvastatin) has been attributed to clopidogrel resistance5,16. In order to evaluate a different effect of these drugs, proton pump inhibitors and statins were analyzed while grouped and stratified as omeprazole and others and lipophilic and hydrophilic statins (pravastatin and rosuvastatin), respectively.

Using the rule of events per variables for binary logistic regression17 and estimating a prevalence of clopidogrel resistance of 45%15 so that it would be possible to include up to eight variables in the multivariate model, the sample would have to include at least 178 patients.

Continuous variables were expressed as mean and standard deviation or median and interquartile range according to the presence or absence of normal distribution evaluated by the Kolmogorov-Smirnov test. Categorical variables were expressed as percentages. In the univariate analysis, the association between clopidogrel resistance and covariates was carried out using Student's t test or Mann-Whitney "U" test for continuous and Chi-square test or Fisher's exact test for categorical variables. To identify independent associations with clopidogrel resistance, multivariate logistic model was built using as independent variables the ones that had an alpha error value < 10% at the univariate analysis. The statistical significance was determined by an alpha error value < 5%. All statistical analysis was performed using the SPSS (Statistical Package for Social Sciences) release 17.0.

The project was approved by the Research Ethics Committee of Hospital Universitário Clementino Fraga Filho-UFRJ, registration # 1120/11.



During the analyzed period, 458 patients underwent elective angioplasty at our service. Of these, 205 (44.7%) were included in the analysis. Figure 1 summarizes the reasons for patient exclusion. The mean platelet aggregation was 37 ± 16%. Seventy-nine patients were resistant to clopidogrel (38.5% 95% CI: 31.9 - 45.2%). The mean platelet aggregation in this group was 54 ± 7% vs. 24.6 ± 12% in the non-resistant group (p <0.001). Chart 1 illustrates this difference. Only 3.9% of patients showed resistance to aspirin and clopidogrel.

The general characteristics of the population and univariate analysis are shown in Table 1. The value of glycemia, previous AMI and response to aspirin were associated with greater occurrence of resistance (96.5 [IQ = 88-112.3] versus 103 [IQ = 95-130] p <0.001, 15.1 x 26.6%, p = 0.043 and 4 [IQ = 2-6] 6 x [IQ = 4-12], p <0.001, respectively for non-resistants and resistants). There was no association between use of proton pump inhibitors (12.7 x 8.9%, p = 0.397) or lipophilic statins, atorvastatin and simvastatin (56.3 x 46.8%, p = 0.375) and clopidogrel resistance.

In the multivariate analysis, all three were independently associated with resistance to clopidogrel. Table 2 summarizes the multivariate analysis.



We observed a high prevalence of resistance to clopidogrel (38.5%) in this population, higher than the values found in the four meta-analyzes: 33.29, 2510, 26.411, and 21%12.

Aradi et al.9 analyzed the stratified prevalence through a diagnostic method and the clinical context. When selecting studies involving stable patients on chronic therapy with clopidogrel and whose platelet aggregation was measured with light transmission aggregometry (LTA) with ADP of 5 µmoles/L, considering the maximum aggregation value as defining resistance, the result is extremely similar: 37.5% (95% CI: 30.9 - 44.1%)18,19. The high variability in prevalence of clopidogrel resistance found in the literature may therefore be attributed to the heterogeneity of assessment methods, treatment regimens and clinical settings studied.

Glycemia, history of AMI and antiaggregant response to aspirin showed an independent association with the occurrence of clopidogrel resistance.

Diabetes and glucose control determine the predictors of clopidogrel resistance in most studies20,21. Within the diabetic population, some studies show that glycemic control, in most of them measured by glycosylated hemoglobin, has an even more deleterious effect on the antiplatelet therapy profile than the disease itself22,23. Angiolillo et al.24 showed that in diabetic patients receiving dual antiplatelet therapy, a high value of platelet aggregation increases the risk of major cardiac events (OR = 3.96 95% CI: 1.8 - 8.7).

We, however, observed an association between the occurrence of clopidogrel resistance and blood glucose level (OR = 1.014, 95% CI: 1.004 - 1.023) and not with the presence of diabetes. The effect remains when only nondiabetic patients are included in the multivariate model (OR = 1.021 95% CI: 1.007 - 1.036).

Cardiovascular risk is related to glycemic control, regardless of diabetes diagnosis. In the study by Selvin et al.25, each percentage point of HbA1c > 4.6% has a RR = 2.36 (95% CI: 1.43 - 3.90) in nondiabetic patients. Although there are no studies that attribute the increased risk to platelet hyperreactivity or antiplatelet resistance, this is biologically plausible.

Other authors also observed a positive correlation between resistance to clopidogrel and aspirin resistance. Gori et al.26, using a platelet aggregation assessment method similar to that used in this study, showed a correlation coefficient of 0.536 (p < 0.001). Half of clopidogrel-resistant patients were also resistant to aspirin. The occurrence of dual resistance was an independent predictor of stent thrombosis and cardiac death.

Lev et al.27, using another method for platelet aggregation assessment, showed that 47.4% of patients resistant to aspirin were also clopidogrel-resistant.

The presence of a previous history of AMI as one of the independent associations with clopidogrel resistance is a unique finding of this study. However, Gurbel et al.8 found some data that might explain it. In their study, there was a trend toward greater use of angiotensin-converting enzyme (ACE) inhibitors in resistant patients (57 vs. 81%, p = 0.08). Moreover, there was a difference of 18% of patients with previous AMI in the resistant group, when compared to the non-resistant one (44 x 26%). In absolute numbers, this represents a difference greater than that found in this study (11.5%). This difference did not reach statistical significance due to the small sample size (n = 100). Patients with prior AMI have a higher likelihood of using ACE inhibitors. Unfortunately we cannot prove this hypothesis, as the use of ACE inhibitors was not one of the analyzed variables.

To our knowledge, this is the first national study to determine the prevalence and associations of clopidogrel resistance. A rational incorporation of new antiplatelet aggregation strategies starts with a better understanding of the clinical significance of this condition in our country.

This study has some limitations:

• Retrospective design that hinders variable control;

• Absolute majority of the patients were Caucasian, making it difficult to extrapolate these results to other ethnicities;

• PA can increase up to 7% immediately after stent implantation28;

• PA improvement may be a temporary effect. A recent study suggests that the value 30 days after stent implantation has a better correlation with long-term events29;

• There was no genetic evaluation of patients in order to assess other causes of resistance;

• Although it was carried out in the usual investigation format, the prior use of clopidogrel could have been assessed through an adherence questionnaire;

• We did not evaluate the use of other medications already associated with clopidogrel resistance, such as losartan and imidazole derivatives.



In this sample we found a high prevalence of clopidogrel resistance in patients who underwent elective angioplasty. The levels of blood glucose, history of previous AMI and response to aspirin were independently associated with this condition.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Sources of Funding

There were no external funding sources for this study.

Study Association

This article is part of the master thesis submitted by Fabrício Braga da Silva, from UFRJ.



1. Mattos LA, Lemos Neto PA, Rassi AJ, Marin-Neto JA, Sousa AGMR, Devito FS. Diretrizes da Sociedade Brasileira de Cardiologia – Intervenção Coronária Percutânea e Métodos Adjuntos Diagnósticos em Cardiologia Intervencionista Arq Bras Cardiol. 2008;91(6 supl. 1):1-58.         [ Links ]

2. Schomig A, Neumann FJ, Kastrati A, Schühlen H, Blasini R, Hadamitzky M, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med. 1996;334(17):1084-9.         [ Links ]

3. Bhatt DL, Bertrand ME, Berger PB, L'Allier PL, Moussa I, Moses JW, et al. Meta-analysis of randomized and registry comparisons of ticlopidine with clopidogrel after stenting. J Am Coll Cardiol. 2002;39(1):9-14.         [ Links ]

4. Momary KM, Dorsch MP, Bates ER. Genetic causes of clopidogrel nonresponsiveness: which ones really count? Pharmacotherapy. 2010;30(3):265-74.         [ Links ]

5. Cuisset T, Frere C, Quilici J, Poyet R, Gaborit B, Bali L, et al. Comparison of omeprazole and pantoprazole influence on a high 150-mg clopidogrel maintenance dose the PACA (Proton Pump Inhibitors And Clopidogrel Association) prospective randomized study. J Am Coll Cardiol. 2009;54(13):1149-53.         [ Links ]

6. Siller-Matula JM, Lang I, Christ G, Jilma B. Calcium-channel blockers reduce the antiplatelet effect of clopidogrel. J Am Coll Cardiol. 2008;52(19):1557-63.         [ Links ]

7. Mangiacapra F, Patti G, Peace A, Gatto L, Vizzi V, Ricottini E, et al. Comparison of platelet reactivity and periprocedural outcomes in patients with versus without diabetes mellitus and treated with clopidogrel and percutaneous coronary intervention. Am J Cardiol. 2010;106(5):619-23.         [ Links ]

8. Gurbel PA. Clopidogrel for coronary stenting: response variability, drug resistance, and the effect of pretreatment platelet reactivity. Circulation. 2003;107(23):2908-13.         [ Links ]

9. Aradi D, Komocsi A, Vorobcsuk A, Rideg O, Tokés-Füzesi M, Magyarlaki T,et al. Prognostic significance of high on-clopidogrel platelet reactivity after percutaneous coronary intervention: systematic review and meta-analysis. Am Heart J. 2010;160(3):543-51.         [ Links ]

10. Combescure C, Fontana P, Mallouk N, Berdague P, Labruyere C, Barazer I, et al. Clinical implications of clopidogrel non-response in cardiovascular patients: a systematic review and meta-analysis. J Thromb Haemost. 2010;8(5):923-33.         [ Links ]

11. Snoep J, Hovens M, Eikenboom J, Vanderbom J, Jukema J, Huisman M. Clopidogrel nonresponsiveness in patients undergoing percutaneous coronary intervention with stenting: a systematic review and meta-analysis. Am Heart J. 2007;154(2):221-31.         [ Links ]

12. Sofi F, Marcucci R, Gori AM, Giusti B, Abbate R, Gensini GF. Clopidogrel non-responsiveness and risk of cardiovascular morbidity. Thromb Haemost. 2010;103(4):841-8.         [ Links ]

13. Gurbel PA, Antonino MJ, Bliden KP, Dichiara J, Suarez TA, Singla A, et al. Platelet reactivity to adenosine diphosphate and long-term ischemic event occurrence following percutaneous coronary intervention: a potential antiplatelet therapeutic target. Platelets. 2008;19(8):595-604.         [ Links ]

14. White MM, Jennings LK. Platelet protocol research and clinical laboratory procedure. Cambridge: Academic Press; 1999.         [ Links ]

15. Breet NJ, van Werkum JW, Bouman HJ, Kelder JC, Ruven HJ, Bal ET et al. Comparison of platelet function tests in predicting clinical outcome in patients undergoing coronary stent implantation. JAMA. 2010;303(8):754-62.         [ Links ]

16. Ratz Bravo AE, Tchambaz L, Krahenbuhl-Melcher A, Hess L, Schlienger RG, Krahenbuhl S. Prevalence of potentially severe drug-drug interactions in ambulatory patients with dyslipidaemia receiving HMG-CoA reductase inhibitor therapy. Drug Saf. 2005;28(3):263-75.         [ Links ]

17. Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR. A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol. 1996;49(12):1373-9.         [ Links ]

18. Bliden KP, DiChiara J, Tantry US, Bassi AK, Chaganti SK, Gurbel PA. Increased risk in patients with high platelet aggregation receiving chronic clopidogrel therapy undergoing percutaneous coronary intervention: is the current antiplatelet therapy adequate? J Am Coll Cardiol. 2007;49(6):657-66.         [ Links ]

19. Aradi D, Konyi A, Palinkas L, Berki T, Pintér T, Tahin T, et al. Thienopyridine therapy influences late outcome after coronary stent implantation. Angiology. 2008;59(2):172-8.         [ Links ]

20. Park KW, Park JJ, Jeon KH, Kang SH, Oh IY, Yang HM, et al. Clinical predictors of high posttreatment platelet reactivity to clopidogrel in Koreans. Cardiovasc Ther. 2012;30(1):5-11.         [ Links ]

21. Price MJ, Nayak KR, Barker CM, Kandzari DE, Teirstein PS. Predictors of heightened platelet reactivity despite dual-antiplatelet therapy in patients undergoing percutaneous coronary intervention. Am J Cardiol. 2009;103(10):1339-43.         [ Links ]

22. Demirtunc R, Duman D, Basar M, Bilgi M, Teomete M, Garip T. The relationship between glycemic control and platelet activity in type 2 diabetes mellitus. J Diabetes Complications. 2009;23(2):89-94.         [ Links ]

23. Singla A, Antonino MJ, Bliden KP, Tantry US, Gurbel PA. The relation between platelet reactivity and glycemic control in diabetic patients with cardiovascular disease on maintenance aspirin and clopidogrel therapy. Am Heart J. 2009;158(5):784. e1-6.         [ Links ]

24. Angiolillo DJ, Bernardo E, Sabate M, Jimenez-Quevedo P, Costa MA, Palazuelos J, et al. Impact of platelet reactivity on cardiovascular outcomes in patients with type 2 diabetes mellitus and coronary artery disease. J Am Coll Cardiol. 2007;50(16):1541-7.         [ Links ]

25. Selvin E, Coresh J, Golden SH, Brancati FL, Folsom AR, Steffes MW. Glycemic control and coronary heart disease risk in persons with and without diabetes: the atherosclerosis risk in communities study. Arch Intern Med. 2005;165(16):1910-6.         [ Links ]

26. Gori AM, Marcucci R, Migliorini A, Valenti R, Moschi G, Paniccia R, et al. Incidence and clinical impact of dual nonresponsiveness to aspirin and clopidogrel in patients with drug-eluting stents. J Am Coll Cardiol. 2008;52(9):734-9.         [ Links ]

27. Lev EI, Patel RT, Maresh KJ, Guthikonda S, Granada J, DeLao T, et al. Aspirin and clopidogrel drug response in patients undergoing percutaneous coronary intervention: the role of dual drug resistance. J Am Coll Cardiol. 2006;47(1):27-33.         [ Links ]

28. Gurbel P, Cummings CC, Bell CR, Alford AB, Meister AF, Serebruany VL; Plavix Reduction Of New Thrombus Occurrence (PRONTO) trial. Onset and extent of platelet inhibition by clopidogrel loading in patients undergoing elective coronary stenting: The Plavix Reduction Of New Thrombus Occurrence (PRONTO) trial. Am Heart J. 2003;145(2):239-47.         [ Links ]

29. Campo G, Parrinello G, Ferraresi P, Lunghi B, Tebaldi M, Miccoli M, et al. Prospective evaluation of on-clopidogrel platelet reactivity over time in patients treated with percutaneous coronary intervention relationship with gene polymorphisms and clinical outcome. J Am Coll Cardiol. 2011;57(25):2474-83.         [ Links ]



Mailing Address:
Fabrício Braga da Silva
Rua Oliveira Rocha, 47/203, Jardim Botânico
Postal Code 22461070, Rio de Janeiro, RJ – Brazil

Manuscript received January 31, 2012
manuscript revised February 10, 2012
accepted August 1, 2012

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License