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List of abbreviations

All abbreviations that have been used in this report are listed here unless the abbreviation is well known (e.g. NHS), or it has been used only once, or it is a non-standard abbreviation used only in figures/tables/appendices, in which case the abbreviation is defined in the figure legend or in the notes at the end of the table.

Conclusions

For patients with ischaemic stroke/TIA, MRD + ASA followed by ASA, followed by clopidogrel, appears to be a cost-effective approach to the prevention of future occlusive vascular events.

Background

Cardiovascular disease' is an umbrella term that includes coronary heart disease, peripheral arterial disease and cerebrovascular disease. Cardiovascular disease is commonly caused by arteries becoming narrowed through atherosclerosis; it is the main cause of death in the UK, accounting for 35% of deaths each year (almost 198,000). Almost half (48%) of all cardiovascular disease deaths are from coronary heart disease, with stroke making up a further quarter (28%). In addition to being the main cause of death, cardiovascular disease is also the major cause of premature death (< 75 years) in the UK; cardiovascular disease caused 30% of premature death in men and 22% in women in 2006.

Executive summary

Occlusive vascular events such as myocardial infarction (MI), ischaemic stroke and transient ischaemic attack (TIA) are the result of a reduction in blood flow associated with an artery becoming narrow or blocked through atherosclerosis and atherothrombosis. Peripheral arterial disease is the result of narrowing of the arteries that supply blood to the muscles and other tissues, usually in the lower extremities. Patients with symptomatic peripheral arterial disease (typically intermittent claudication) are at increased risk of experiencing an initial occlusive vascular event. Given the nature of the health problem, some people have multivascular disease, disease in more than one vascular bed, and appear to be at even greater risk of death, MI or stroke than those with disease in a single vascular bed. The primary objective in the treatment of all patients with a history of occlusive vascular events and peripheral arterial disease is to prevent the occurrence of new occlusive vascular events.

Assessment of cost-effectiveness

There are three distinct elements to this section on cost-effectiveness. First, a critical appraisal of the existing economic evidence describing clopidogrel and MRD since the publication of the previous NICE guidance (TA90) is presented. Second, a critique of the two economic models submitted by the manufacturers is described. Third, the results of the Assessment Group's de novo economic evaluation are presented and summarised. It should be noted that a substantive amount of the analysis of cost-effectiveness was based on confidential data provided by the manufacturers. This document has been edited as appropriate so as to maintain confidentiality.

Assessment of clinical effectiveness

Methods for reviewing clinical effectiveness and cost-effectiveness evidence are described in this chapter.

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