BMJ  2005;330 (8 January), doi:10.1136/bmj.330.7482.0-e

Filler

POEM^*

Optimal oral antiplatelet therapy for vascular disease

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

Synopsis Aspirin prevents recurrent vascular events in a wide range of high risk patients, but it is unknown if other antiplatelet agents, such as clopidogrel or dipyridamole, alone or in combination with aspirin, are more effective. The investigators rigorously searched multiple databases including Medline, the Cochrane clinical trials registry, and reference lists of trials, review articles, and scientific statements and guidelines of official societies. They included randomised trials comparing an antiplatelet regimen to either placebo or another antiplatelet regimen assessing outcomes for at least 10 days. They identified 111 trials enrolling nearly 100 000 patients. The investigators do not state if the search for, and evaluation of, the included studies was done independently by more than one person. No formal assessment of the potential for publication bias was done, nor was any specific analysis done to determine homogeneity of the results. Recommended oral first line antiplatelet therapy is aspirin for patients with ST segment elevation myocardial infarction; aspirin or clopidogrel for those with initial transient ischaemic attack (TIA) or ischaemic stroke, chronic stable angina, or peripheral arterial disease (since aspirin is less expensive, clopidogrel should be reserved only for patients who do not tolerate aspirin); and aspirin plus clopidogrel for those with non-ST segment elevation acute coronary syndrome. For second line therapy, the combination of aspirin and clopidogrel is recommended for recurrent acute coronary syndrome. The combination of aspirin and clopidogrel does not, however, lower the incidence of recurrent vascular events in patients with recurrent TIA or ischaemic stroke, but does increase the risk of major and life threatening bleeding. The combination of aspirin and extended release dipyridamole is therefore recommended for patients with recurrent TIA or ischaemic stroke in the absence of known coronary artery disease. Because of the theoretical risk of dipyridamole exacerbating myocardial ischaemia, further studies are needed before firm recommendations can be made on the management of patients with both recurrent TIA or ischaemic stroke and known coronary artery disease. Ticlopidine is beneficial for various vascular conditions, but common side effects—some serious—limit its usefulness.

Bottom line Aspirin is the recommended oral first line antiplatelet therapy for patients with ST segment elevation myocardial infarction. Aspirin or clopidogrel is recommended for those with initial TIA or ischaemic stroke, chronic stable angina, or peripheral arterial disease, and aspirin plus clopidogrel should be used for those with non-ST segment elevation acute coronary syndrome. For second line therapy, the combination of aspirin and clopidogrel is recommended for recurrent acute coronary syndrome. The combination of aspirin and extended release dipyridamole is recommended for patients with recurrent TIA or ischaemic stroke in the absence of known coronary artery disease.

Level of evidence 1a (see www.infopoems.com/levels.html). Systematic review of randomised trials displaying worrisome heterogeneity.

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Tran H, Anand SS. Oral antiplatelet therapy in cerebrovascular disease, coronary artery disease, and peripheral arterial disease. JAMA 2004;292: 1867-74[Abstract/Free Full Text].

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^* Patient-Oriented Evidence that Matters. See editorial ( BMJ 2002;325: 983[Free Full Text])

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