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Aspirin and anticoagulation with warfarin have been the mainstays of secondary stroke prevention. However, questions remain as to whether antiplatelet therapy or anticoagulation is superior and whether the two are synergistic in stroke prevention. This review highlights new advances in stroke prevention in 2002 using these agents. We conclude by exploring possible areas for future inquiry.Aspirin has only a modest but significant benefit in preventing recurrent stroke. Anticoagulation has been viewed as a more potent agent than aspirin, particularly given the success of warfarin in stroke prevention in patients with nonrheumatic atrial fibrillation.1,2 The Warfarin-Aspirin Recurrent Stroke Study (WARSS) examined this potential superiority of warfarin compared with aspirin.3WARSS involved the randomization of 2206 patients to active-aspirin (325 mg) and warfarin-placebo or active-warfarin and aspirin-placebo with follow-up for 2 years. Randomization occurred within 30 days of an ischemic stroke, in cases in which no cardiac source was suspected and no surgery for a high-grade carotid stenosis was planned. The trial was double-blinded, and the trial organizers are to be commended their efforts to maintain blinding, with plausible false international normalized ratio (INR) values generated for those randomized to warfarin-placebo. The dose of warfarin was adjusted to achieve and maintain a range of INR from 1.4 to 2.8.The trial failed to show a benefit of warfarin compared with aspirin. Warfarin was associated with a nonsignificant additional risk of stroke or death compared with aspirin (17.8% receiving warfarin versus 16.0% receiving aspirin). Safety, in terms of major hemorrhage, was comparable between the groups (3.4% receiving warfarin versus 2.7% receiving aspirin). However, questions remain. Although it cannot be argued that all patients should receive warfarin, it also cannot be unequivocally stated that the two therapies are of equal value, because the trial was not powered to show this.Was …

Ever Decreasing Circles: Advances in Antiplatelet Therapy and Anticoagulation