Antiplatelet therapy with clopidogrel and aspirin in vascular diseases: clinical evidence for and against the combination

The focus of this review is to discuss the hypothesis that justifies the use of dual antiplatelet therapy of aspirin and clopidogrel versus monotherapy with aspirin in arterial vascular disease. By analyzing the CLARITY-TIMI and COMMIT trials, the authors discuss the appropriate use of aspirin plus clopidogrel for patients suffering acute myocardial infarction. In contrast, in the CHARISMA trial, the combination was not justified in stable high-risk patients with documented coronary disease, cerebrovascular disease or symptomatic peripheral artery disease. In two additional cardiovascular studies, the CURE and the PCI-CURE trials, the benefit of the drug combination was evident in those patients who underwent percutaneous coronary intervention and coronary artery bypass grafting. Finally, two focused cerebrovascular studies, the CARESS and the MATCH trials, were analyzed. The CARESS trial demonstrated the clinical benefit of this combination in an acute clinical setting. However, the combination proved to be ineffective in the longer-term MATCH trial. It appears from these large clinical trials that the risk-benefit of dual antiplatelet therapy with aspirin and clopidogrel is justified in high-risk symptomatic patients but not in asymptomatic patients. The exact dose regimen and duration of combination therapy await definition and require careful assessment to optimize the anticoagulant benefit, while minimizing the hemorrhagic risk.