Kyrillos Guirguis


St. Vincent's Health, Fitzroy, Australia 3065

An unforeseen consequence of poor medication counselling

“Self care in the form of compliance with prescribed treatment regimens may be particularly important in patients with serious long term conditions. Often patients undergoing surgery, or other therapeutic procedures, are required to take medication or adopt an array of lifestyle changes subsequently in order to maximise the benefits, or minimise adverse events. Adherence to these measures is important and often stressed during consultations to obtain consent before a procedure.

I recently attended an elderly lady who had severe ischaemic heart disease that required angiography. Often angioplasty is performed within the same procedural session to relieve the stenosis, placing a stent that allows improved perfusion through the narrowed vessel. However this lady insisted on not undergoing the therapeutic procedure despite knowing how life saving it could be for her.

On questioning her about her decision she recalled that she had been told ‘I will have a very bad stroke if I miss the tablet for one day‘, in the consultation before the procedure. It transpired that she was referring to clopidogrel, an antiplatelet medication used after stenting to prevent re-stenosis. Recent evidence suggests that good compliance is important with clopidogrel, in order to prevent an increased risk of cardiovascular events. Indeed, the cessation of clopidogrel after initially using it following stenting has been speculated to increase the risk of such events1-4. This has led some clinicians to call for indefinite use of the drug in some patients5.

My patient was too scared to take the tablet and end up with a stroke if she happened to forget to take it for one single day. To counsel perfect compliance is not realistic, and health practitioners must be wary that well-intentioned warnings can be counterproductive and lead to unintended consequences.

Following a discussion on the role of clopidogrel and the spirit of the initial instruction about adherence, she promised to seriously consider the procedure. The result was a successful angioplasty and a happy healthier patient.

I have learnt that rigorous attempts to get people to do the right thing by themselves e.g. comply with medications, are fraught with difficulty. We should educate patients on the importance of adherence, but be realistic in our demands and alert to clues that the patient may have missed the point that we try to get across. I report this unintended consequence to add to the challenges to be aware of when discussing compliance with medication.”

Correspondence to: Kyrillos Guirguis BSc BPharm MClinPharm (candidate) AACPA, Outreach Pharmacist, St Vincent’s Health, Fitzroy, Australia 3065.  Email: kyrillos.guirguis@svhm.org.au.


  1. Chrissoheris M.P., Mruthyunjayanna V., and Donohue T.J., Late thrombosis of drug-eluting stents after discontinuation of clopidogrel: Report of two cases and review of the literature. Connecticut Medicine., 2006. 70(8): p. 485-490.
  2. Jimenez-Quevedo P., et al., Late Stent Thrombosis (> 1 Year) Following Clopidogrel Withdrawal after Brachytherapy Treatment: Need to Assess Aspirin Resistance?. Catheterization and Cardiovascular Interventions., 2004. 62(1): p. 39-42.
  3. Ho P.M., et al., Clopidogrel and long-term outcomes after stent implantation for acute coronary syndrome. American Heart Journal, 2007. 154(5): p. 846-851.
  4. Tie S., et al., Timing of thrombotic events in patients receiving 2 weeks of clopidogrel therapy post bare metal coronary artery stenting: a New Zealand retrospective study. New Zealand Medical Journal, 2007. 120(1255): p. U2553.
  5. Brar, S.S., et al., Long-Term Outcomes by Clopidogrel Duration and Stent Type in a Diabetic Population With De Novo Coronary Artery Lesions. Journal of the American College of Cardiology, 2008. 51(23): p. 2228-2229.