A Little Good...
My grandmother used to say: "If a little'll do a little good, a lot'll do a lotta good." Unfortunately, it is not that simple with antiplatelet agents.
Many relevant facts are well-established. In identifiable subgroups of patients who present with TIA or minor stroke, the risk of a subsequent stroke is high.1-3 Most of this risk is incurred during the first few days after a warning event.2 Aspirin and other antiplatelet agents can lower the risk of secondary stroke by approximately 12-22%.4,5 In patients with acute coronary syndromes, another thrombotic disorder, dual antiplatelet therapy offers a greater risk reduction than aspirin alone, at the expense of increased hemorrhagic risk.6 In symptomatic and asymptomatic patients, dual antiplatelet therapy with clopidogrel and aspirin is better than aspirin alone in reducing microembolic signals detected by transcranial Doppler ultrasound as evidence of plaque-related embolism.7,8 The extended use of aspirin plus clopidogrel confers an increased risk of moderate-to-severe hemorrhage when compared to either agent alone.9-11 Early trials of dual antiplatelet therapy for secondary stroke prevention have shown either no benefit or a benefit that was counterbalanced by the increased risk of significant hemorrhage.9,10,12 Dual antiplatelet therapy was a component of a successful regimen of secondary prevention in patients with symptomatic intracranial stenosis in the recent SAMMPRIS trial.13
- Received September 9, 2013.
- Accepted September 10, 2013.