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The dogma of aspirin: a critical review of evidence on the best monotherapy after dual antiplatelet therapy.

Polo Friz H, Molteni M, Cimminiello C - Thromb J (2015)

Bottom Line: Dual antiplatelet therapy based on the combination of an adenosine diphosphate (ADP)-receptor antagonist plus aspirin has demonstrated to be more effective in reducing the rate of major ischemic vascular events compared to aspirin monotherapy in some clinical settings.We conclude that, whether ADP-receptor antagonist rather than aspirin may be proposed as monotherapy seems not only have no answer but also not place in the current specialists' analysis, as if a dogmatic approach were prevalent.Perhaps the time for an open debate on these topics is ripe.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Vimercate Hospital Azienda Ospedaliera di Desio e Vimercate, Vimercate, Italy.

ABSTRACT
Dual antiplatelet therapy based on the combination of an adenosine diphosphate (ADP)-receptor antagonist plus aspirin has demonstrated to be more effective in reducing the rate of major ischemic vascular events compared to aspirin monotherapy in some clinical settings. The current controversy on the duration of dual antiplatelet therapy should not conceal another major issue: the choice of the more appropriate antiplatelet monotherapy after the dual treatment phase. The aim of this article is to critically analyze the available evidence in this topic. Data from studies like CAPRIE, MATCH, PROFESS, CHANCE, DAPT and others, raise questions as why antiplatelet monotherapy after the dual phase should only be based on aspirin, in spite of a lack of evidence surprisingly not highlighted by key opinion leaders and experts. We conclude that, whether ADP-receptor antagonist rather than aspirin may be proposed as monotherapy seems not only have no answer but also not place in the current specialists' analysis, as if a dogmatic approach were prevalent. Perhaps the time for an open debate on these topics is ripe.

No MeSH data available.


Related in: MedlinePlus

Risk of stroke during different phases (first 21 days, from 22nd to 60th day, from 61st to 90th day) of the CHANCE study [10, 11] follow-up period. Overall benefit in favour of aspirin-clopidogrel: hazard ratio, 0.68 (95 % CI, 0.57–0.81) P < 0.001
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Fig1: Risk of stroke during different phases (first 21 days, from 22nd to 60th day, from 61st to 90th day) of the CHANCE study [10, 11] follow-up period. Overall benefit in favour of aspirin-clopidogrel: hazard ratio, 0.68 (95 % CI, 0.57–0.81) P < 0.001

Mentions: In 2013, Wang and colleagues reported the results of the Clopidogrel in High- Risk Patients with Acute Non disabling Cerebrovascular Events (CHANCE) trial [10, 11] which enrolled 5170 patients with acute minor ischemic stroke or TIA at high risk for recurrence and, unlike MATCH study, within 24 h of symptom onset. The addition of clopidogrel to aspirin in comparison to aspirin alone reduced the relative risk of recurrent stroke at 90 days by 32 % (8.2 % vs. 11.7 %; hazard ratio, 0.68; 95 % CI, 0.57 to 0.81) with no difference between the group that received both groups in the incidence of moderate or severe hemorrhage (0.3 % in each group; P = 0.73) or hemorrhagic stroke (0.3 % in each group; P = 0.98). The study demonstrated a substantial treatment effect with a number-needed-to-treat of 29 for preventing one recurrent stroke. That is, treating 29 patients for 90 days with clopidogrel plus aspirin for the first 21 days, followed by clopidogrel alone from day 22 to day 90, prevented one stroke, as compared with aspirin alone. Is noticeable that most of the absolute benefit of clopidogrel plus aspirin is obtained within the first few days after the ischemic event. The strategy adopted in the CHANCE study to employ dual antiplatelet therapy for less than a month and then switch to a single agent is proof of how the lesson of MATCH has been carefully read thus avoiding to pay a too high tribute in terms of intracranial hemorrhage since in MATCH intracranial hemorrhages were becoming significantly more frequent in the group of combined therapy after the first quarter [19, 20]. The benefit shown by clopidogrel monotherapy compared with aspirin in the days between 22 and 90 once again underlines, in an unbiased reading of CHANCE, the issue already emerged in the MATCH of clopidogrel as better candidate for antiplatelet monotherapy after the dual phase, Fig. 1, and the PROFESS findings still in patients with ischemic stroke are consistent with this evidence [21].Fig. 1


The dogma of aspirin: a critical review of evidence on the best monotherapy after dual antiplatelet therapy.

Polo Friz H, Molteni M, Cimminiello C - Thromb J (2015)

Risk of stroke during different phases (first 21 days, from 22nd to 60th day, from 61st to 90th day) of the CHANCE study [10, 11] follow-up period. Overall benefit in favour of aspirin-clopidogrel: hazard ratio, 0.68 (95 % CI, 0.57–0.81) P < 0.001
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4561422&req=5

Fig1: Risk of stroke during different phases (first 21 days, from 22nd to 60th day, from 61st to 90th day) of the CHANCE study [10, 11] follow-up period. Overall benefit in favour of aspirin-clopidogrel: hazard ratio, 0.68 (95 % CI, 0.57–0.81) P < 0.001
Mentions: In 2013, Wang and colleagues reported the results of the Clopidogrel in High- Risk Patients with Acute Non disabling Cerebrovascular Events (CHANCE) trial [10, 11] which enrolled 5170 patients with acute minor ischemic stroke or TIA at high risk for recurrence and, unlike MATCH study, within 24 h of symptom onset. The addition of clopidogrel to aspirin in comparison to aspirin alone reduced the relative risk of recurrent stroke at 90 days by 32 % (8.2 % vs. 11.7 %; hazard ratio, 0.68; 95 % CI, 0.57 to 0.81) with no difference between the group that received both groups in the incidence of moderate or severe hemorrhage (0.3 % in each group; P = 0.73) or hemorrhagic stroke (0.3 % in each group; P = 0.98). The study demonstrated a substantial treatment effect with a number-needed-to-treat of 29 for preventing one recurrent stroke. That is, treating 29 patients for 90 days with clopidogrel plus aspirin for the first 21 days, followed by clopidogrel alone from day 22 to day 90, prevented one stroke, as compared with aspirin alone. Is noticeable that most of the absolute benefit of clopidogrel plus aspirin is obtained within the first few days after the ischemic event. The strategy adopted in the CHANCE study to employ dual antiplatelet therapy for less than a month and then switch to a single agent is proof of how the lesson of MATCH has been carefully read thus avoiding to pay a too high tribute in terms of intracranial hemorrhage since in MATCH intracranial hemorrhages were becoming significantly more frequent in the group of combined therapy after the first quarter [19, 20]. The benefit shown by clopidogrel monotherapy compared with aspirin in the days between 22 and 90 once again underlines, in an unbiased reading of CHANCE, the issue already emerged in the MATCH of clopidogrel as better candidate for antiplatelet monotherapy after the dual phase, Fig. 1, and the PROFESS findings still in patients with ischemic stroke are consistent with this evidence [21].Fig. 1

Bottom Line: Dual antiplatelet therapy based on the combination of an adenosine diphosphate (ADP)-receptor antagonist plus aspirin has demonstrated to be more effective in reducing the rate of major ischemic vascular events compared to aspirin monotherapy in some clinical settings.We conclude that, whether ADP-receptor antagonist rather than aspirin may be proposed as monotherapy seems not only have no answer but also not place in the current specialists' analysis, as if a dogmatic approach were prevalent.Perhaps the time for an open debate on these topics is ripe.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Vimercate Hospital Azienda Ospedaliera di Desio e Vimercate, Vimercate, Italy.

ABSTRACT
Dual antiplatelet therapy based on the combination of an adenosine diphosphate (ADP)-receptor antagonist plus aspirin has demonstrated to be more effective in reducing the rate of major ischemic vascular events compared to aspirin monotherapy in some clinical settings. The current controversy on the duration of dual antiplatelet therapy should not conceal another major issue: the choice of the more appropriate antiplatelet monotherapy after the dual treatment phase. The aim of this article is to critically analyze the available evidence in this topic. Data from studies like CAPRIE, MATCH, PROFESS, CHANCE, DAPT and others, raise questions as why antiplatelet monotherapy after the dual phase should only be based on aspirin, in spite of a lack of evidence surprisingly not highlighted by key opinion leaders and experts. We conclude that, whether ADP-receptor antagonist rather than aspirin may be proposed as monotherapy seems not only have no answer but also not place in the current specialists' analysis, as if a dogmatic approach were prevalent. Perhaps the time for an open debate on these topics is ripe.

No MeSH data available.


Related in: MedlinePlus