Context Atherothrombosis is a pathophysiologic process that results in clinical
ischemic events affecting the cerebral, coronary, and peripheral arterial
circulation. Antiplatelet agents, used alone or in combination, are effective
in preventing recurrent vascular events among individuals with established
Objective To summarize the current state of evidence regarding oral antiplatelet
treatment in patients with cerebrovascular disease, coronary artery disease
(CAD), and peripheral arterial disease.
Evidence Acquisition Using the key terms acute coronary syndrome, atherothrombosis, ischemic stroke, myocardial infarction, MI, peripheral
arterial disease, TIA, transient
ischemic attack, unstable angina,aspirin,ticlopidine,dipyridamole, and clopidogrel, we searched the
MEDLINE database as well as the trial register of the Cochrane Groups to identify
studies published from 1960 to August 2004. We manually searched journals
and abstract booklets; scrutinized reference lists of trials and review articles;
and reviewed meta-analyses, scientific statements, and guidelines from official
Evidence Synthesis Appropriate oral first-line antiplatelet therapy is aspirin for individuals
with ST-segment elevation myocardial infarction; aspirin or clopidogrel for
those with TIA or stroke, chronic stable angina, or peripheral arterial disease;
and aspirin combined with clopidogrel for those with non–ST-segment
elevation acute coronary syndrome. Aspirin combined with dipyridamole is a
possible alternative for patients who experience a first episode of TIA or
stroke in the absence of clinically apparent CAD. Although ticlopidine has
been shown to be of benefit in various vascular conditions, its adverse-effect
profile has limited its use.
Conclusions Aspirin, ticlopidine, clopidogrel, aspirin combined with clopidogrel,
and aspirin combined with dipyridamole are effective in preventing recurrent
vascular events among various subgroups of patients with vascular disease.
Current clinical trial evidence favors the use of aspirin or clopidogrel as
first-line agents for the majority of patients with vascular disease. Clinical
trials evaluating combination antiplatelet therapies will direct future practice.