Antiplatelets for Stroke Prevention

Marc Fisher MD Kennedy Lees MD Section Editors Indirect comparisons of CAPRIE, ESPS-2, and MATCH trials led many stroke experts to favor the combination of aspirin and extended-release dipyridamole (ASA/ERD) over clopidogrel as the preferred antiplatelet therapy for secondary stroke prevention.1–3 The Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) study, a 2×2 factorial, double-blind, event-driven, active and placebo-controlled study of ASA/ERD versus clopidogrel, and the angiotensin receptor blocker, telmisartan, versus placebo in 20 332 patients with a recent ischemic stroke was performed to evaluate the 2 antiplatelet agents directly. No clear winner can be declared, but ASA/ERD, the presumptive favorite, has been bruised and clopidogrel’s role in stroke prevention has been partly restored. A rematch between these rivals appears unlikely.PRoFESS demonstrated that the risks of recurrent stroke or the composite of stroke, myocardial infarction, or vascular death are similar with ASA/ERD and clopidogrel.4 However, increased risks of nonfatal hemorrhagic stroke and side effects leading to discontinuation of therapy were seen with ASA/ERD. Treatment with either ASA/ERD or clopidogrel did not seem to afford neuroprotection. Disability due to stroke and cognitive decline was not different between the 2 antiplatelets.5 There was no interaction between the treatment benefit of the antiplatelets and telmisartan in any outcome measure.A few editorials have already attempted to explain “What went …