Dual Antiplatelet Therapy for Prevention of Recurrent Ischemic Events

Jean Nappi, PharmD, Fccp, Bcps; Robert Talbert, PharmD, Fccp, Bcps

Disclosures

Am J Health Syst Pharm. 2002;59(18) 

In This Article

Abstract and Introduction

Abstract

The advantages of dual antiplatelet therapy over monotherapy in preventing recurrent ischemic events are examined.

Atherosclerosis is an insidious systemic process involving multiple vascular beds, including the cerebral, coronary, and peripheral arteries. Atherosclerotic plaque rupture is one of the inciting events in the progression of platelet activation, aggregation, and thrombus formation. Patients with any clinical manifestation of atherosclerosis are vulnerable to others in different vascular beds since the disease develops throughout the vasculature, and different vascular events have common predisposing risk factors. Ischemic coronary heart disease and cerebrovascular disease are two of the three most frequent causes of death in the United States. The efficacy of aspirin in the secondary prevention of myocardial infarction (MI) and stroke has been demonstrated in numerous trials. While dipyridamole has not been linked with a greater odds reduction than aspirin in the development of MI, stroke, and vascular death, ticlopidine and clopidogrel have been associated with a greater reduction in the development of acute MI, stroke, and vascular death than aspirin. Clinical trials evaluating the efficacy and safety of combination antiplatelet therapy in the prevention of recurrent ischemic events are ongoing. The rationale for using a combination of two mechanistically different antiplatelet agents is supported by ex vivo and clinical studies. Inhibition of platelet aggregation and thrombus formation is enhanced with dual antiplatelet therapy. Combination antiplatelet regimens with different mechanisms of action to inhibit multiple sites in the thrombotic pathway may further improve long-term clinical outcomes.

Dual antiplatelet therapy may have advantages over monotherapy in the prevention of recurrent ischemic events.

Introduction

Ischemic coronary heart disease (CHD) and cerebrovascular disease are the first and third most frequently reported causes of death in the United States, respectively.[1] The American Heart Association has estimated that each year 1.1 million Americans will suffer a new or recurrent coronary event, and 600,000 Americans will experience a new or recurrent stroke resulting in long-term or permanent disability. Other estimates of first or recurrent strokes are as high as 750,000 per year.[2] Survivors of a myocardial infarction (MI) have 1.5-15 times greater risk of illness or death than the general population, with men and women facing a substantial risk of recurrent MI, sudden death, heart failure, and angina pectoris. Sixty-six percent of MI patients will not make a complete recovery; however, 88% of those under age 65 years return to work.[1] Likewise, 15-30% of patients surviving a stroke are permanently disabled. Although the Auckland Stroke Study revealed that, while patients seemed well adjusted psychologically, most stroke survivors assessed their recovery as incomplete and were more likely to be dependent in all daily activities.[3] When the indirect costs of lost productivity due to morbidity and mortality are combined with the direct costs of acute and long-term health care, the total cost of CHD and stroke to patients and society is $146.2 billion per year.[1,4] The high cost of atherosclerotic disease highlights the importance of preventing future events. Currently, antiplatelet agents are recommended for the prevention of recurrent ischemic vascular events.[5,6] Although these agents are primarily used in monotherapy, recent data suggest that outcomes can be improved with dual antiplatelet therapy.

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