Antiplatelet therapy: Views from the experts

Antiplatelet therapy is recommended for stroke prevention in persons with a history of thromboembolic stroke or transient ischemic attack (TIA) that i s not of cardiac origin.(1) Aspirin was the first antiplatelet agent to be used in this context and is still the most frequently prescribed preventive treatment for ischemic stroke.(2) However, because the results of clinical studies with aspirin have been inconsistent, the dose of aspirin required for stroke prevention in persons with cerebrovascular disease has been a su bject of debate among stroke neurologists. In the present discussion, low-d ose aspirin is generally regarded by the experts as equivalent in effective ness to high-dose aspirin, and its higher tolerability has the potential to significantly increase compliance with long-term therapy. Higher aspirin d oses may have clinical utility in particular settings, but this requires fu rther study. Despite the controversy, aspirin is now recognized as the trea tment standard against which other antiplatelet agents are compared. Antipl atelet agents that may be more effective than aspirin have now been develop ed. Although each of these agents has been directly compared with aspirin i n a large, randomized clinical trial, the lack of direct comparisons among these alternative antiplatelet therapies complicates decisions regarding lo ng-term care of patients with cerebrovascular disease. An international pan el of stroke neurologists reports that their selection of antiplatelet ther apies for patients with prior history of TIA or stroke depends most heavily on drug efficacy and safety issues and is limited by availability (approva l status of alternatives).