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Dual Antiplatelet Therapy for Patients with Cardiovascular Disease
Am Fam Physician. 2019 Oct 15;100(8):463-464.
Do patients with established cardiovascular disease who do not qualify for coronary stenting or those at increased risk of cardiovascular disease benefit from dual antiplatelet therapy (aspirin plus clopidogrel)?
Patients with established cardiovascular disease or risk factors (e.g., ischemic cerebrovascular disease, peripheral arterial disease, high risk of atherothrombotic disease) should receive dual antiplatelet therapy with aspirin plus clopidogrel, which confers additional benefit over aspirin alone. (Strength of Recommendation [SOR]: A, based on meta-analyses of randomized controlled trials [RCTs].) Dual antiplatelet therapy decreases the risk of myocardial infarction (MI) and ischemic stroke (number needed to treat [NNT] = 77 and 43, respectively) with no change in mortality. It also increases the risks of major and minor bleeding (number needed to harm [NNH] = 111 and 30, respectively). Dual antiplatelet therapy has more benefit in patients who have established cardiovascular disease compared with those who have only risk factors (NNT to reduce composite of MI, stroke, and cardiovascular death = 100; NNT for all-cause mortality = 59). (SOR: B, based on a post hoc analysis of RCTs.)
A 2017 Cochrane meta-analysis found that dual antiplatelet therapy reduced the risk of MI and stroke and increased the risk of bleeding compared with aspirin alone, but it did not reduce mortality in patients with high risk of or known cardiovascular disease.1 Participants had known coronary artery disease, ischemic cerebrovascular disease, peripheral arterial disease, or a high risk of atherothrombotic disease (mean age: 60 to 65 years in most studies; 50% to 90% men). Patients were randomized to treatment with aspirin (70 to 325 mg daily) plus clopidogrel (75 mg daily in all but one RCT, which used 100 mg) vs. aspirin plus placebo for at least 30 days. Patients were followed for a median of 12 months. Dual antiplatelet therapy decreased fatal and nonfatal MI (relative risk
Referencesshow all references
1. Squizzato A, Bellesini M, Takeda A, et al. Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular events. Cochrane Database Syst Rev. 2017;(12):CD005158....
2. Bhatt DL, Fox KA, Hacke W, et al.; CHARISMA Investigators. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354(16):1706–1717.
3. Yusuf S, Zhao F, Mehta SR, et al.; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation [published corrections appear in N Engl J Med. 2001;345(20):1506 and N Engl J Med. 2001;345(23):1716]. N Engl J Med. 2001;345(7):494–502.
4. Vandvik PO, Lincoff AM, Gore JM, et al. Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines [published correction appears in Chest. 2012;141(4):1129]. Chest. 2012;141(2 suppl):e637S–e668S.
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