Original title: Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial Reference: Dewilde WJ et al. Lancet. 2013 Mar 30;381(9872):1107-15

The question to answer was simple, relevant, and is increasingly frequent in everyday practice: what to do when a patient who is anticoagulated has to undergo angioplasty? Therapeutics with single or double antiplatelet therapy with anticoagulation? Researchers in the Dutch trial, an open-design, randomized and controlled 573 patients to two groups: dual antiplatelet therapy of aspirin plus clopidogrel versus clopidogrel alone, with both branches obviously receiving warfarin. The results showed that taking aspirin out of the therapy scheme reduces the risk of bleeding and does not increase the risk of thrombotic events.

The total bleeding was reduced very significantly, (HR 0.36, meaning a decrease of 64%), and although this was from a predominance of minor bleeding, major bleeding also showed a similar trend with similar HR values, ( HR 0.56 major bleeding TIMI, HR 0.40 severe bleeding GUSTO). This indicates that although the difference in major bleeding was not statistically significant due to sample size, the trend was in the same direction and of similar magnitude. As for thrombotic events, although an increase in such cases was not found in the absence of aspirin, the study is small and lacks sufficient power to safely make this statement so these results must be confirmed by other studies. In particular, one cannot know whether removing aspirin in between will not cause more cases of stent thrombosis, a phenomenon of rare occurrence but catastrophic. Other interesting questions are: would the results be the same with new anticoagulants and antiplatelet drugs and what would a third group have shown with aspirin plus anticoagulation but without clopidogrel?

It was considered that this test could be the “first nail in the coffin” of aspirin because it may no longer be necessary to consider it is required in all future antithrombotic studies of coronary patients. Patients at high risk of bleeding and anticoagulated patients are the subject of studies with new antithrombotic drugs in certain clinical scenarios and could be treated, (and it may be useful to be), without aspirin. 

Courtesy of a Dr. Alejandro Lakowsky
MTSAC.

Dr. Alejandro Lakowsky para SOLACI.ORG