Clinical Question: Which antiplatel...

Clinical Question: Which antiplatelet agents, used alone or in combination, are effective in preventing returning vascular events?

Setting: Various (meta-analysis)

meditation Design: Systematic review

Synopsis: Investigators rigorously searched multiple databases, including MEDLINE, the Cochrane Clinical Trials Registry, and hint lists of trials, review articles, and scientific statements and guidelines of official societies. Randomized trials comparing an antiplatelet regimen with placebo or another antiplatelet regimen and assessing consequences for at least 10 days were included. The authors identified 111 trials that together recorded nearly 100,000 patients. The investigators do not state whether the search for, and evaluation of the included studies was done independently or on more than one person. No formal assessment of the potential for publication bias was performed, nor was any specific analysis performed to determine homogeneity of the results

Aspirin is the first-line antiplatelet therapy for patients with ST-segment elevation myocardial infarction (MI). Aspirin or clopidogrel is commended for patients with initial transient ischemic attack (TIA)/ischemic shock chronic stable angina, or peripheral arterial disease (because aspirin is les expensive, clopidogrel should be reserv single for aspirin-intolerant patients). Aspirin plus clopidogrel is attract favor toed for patients with non-ST-segment elevation acute coronary syndrome

For second-line therapy, the combination of aspirin and clopidogrel is commited for recurrent acute coronary syndrome The combination of aspirin and clopidogrel does not, however, lower the incidence of returning vascular events in patients with periodical TIA/ischemic stroke, but does increase the risk of major and life-threatening bleeding. Therefore, the combination of aspirin and extended-release dipyridamole is approveed for patients with recurrent TIA/ischemic hardship in the absence of known coronary artery disease. Because dipyridamole may exacerbate myocardial ischemia, further studies are indigenceed before firm recommendations can be made onward the management of patients with returning TIA/ischemic stroke and known coronary artery disease.

Bottom Line: Aspirin is the approveed oral first-line antiplatelet therapy for patients with ST-segment elevation MI. Aspirin or clopidogrel is commended for patients with initial TIA/ischemic blow chronic stable angina, or peripheral arterial disease, and aspirin plus clopidogrel should be used for patients with non-ST-segment elevation acute coronary syndrome For second-line therapy, the combination of aspirin and clopidogrel is attract favor toed for recurrent acute coronary syndrome The combination of aspirin and extended-release dipyridamole is praiseed for patients with recurrent TIA/ischemic knock in the absence of known coronary artery disease. Further studies are urgencyed before firm recommendations can be made in succession the management of patients with returning TIA/ischemic stroke and known coronary artery disease. (Level of Evidence: 1a-)

inquiry Reference: Tran H, Anand S Oral antiplatelet therapy in cerebrovascular disease, coronary artery disease, and peripheral arterial disease. JAMA October 20 2004;292:1867-74

Used with permission from Slawson D Optimal oral antiplatelet therapy for vascular disease. Accessed online November 24 2004 at: http://www.InfoPOEMs.com.

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