In episode 67, we address ischemic stroke of arterial origin and go over some core therapies (ASA, dipyridamole, clopidogrel and warfarin).  We also discuss complications of anti-thrombotics and the options for patients with a GI bleed on ASA.  Although Peter attempts to guide us through the maze of evidence, all three of us get lost and have trouble finding our way back. Mike rightly corrects James about one of his comments and James responds in a purely professional manner.

Show Notes

1) ASA post-stroke – low dose

ATTC 2009

Lancet 2009;373:1849–60

2) Clopidogrel versus ASA

CAPRIE

Lancet 1996;348:1329–39

3) ASA and clopidogrel versus clopidogrel

CHARISMA

NEJM 2006;354:1706-17

MATCH

Lancet 2004;364:331–37

4) ASA versus warfarin post-stroke

WARSS

NEJM 2001;345:1444-51

5) Dipyridamole plus ASA

ESPS-2

Thromb Res 1998;92:S1-S6

ESPRIT

Lancet 2006;367:1665-75

peterloewen.com

PRoFESS

NEJM 2008;359:1238-51

7) GI bleeding and ASA

PPI added to ASA versus clopidogrel alone

NEJM 2005; 352:238-44

NEJM 2001;344:967-73

H. pylori eradication plus proton pump inhibitor versus H. pylori eradication alone

NEJM 2002;346:2033-8

Clopidogrel plus a PPI – interaction or not

CMAJ 2009;180:713-8

In episode 66, we embark on a journey of epic proportions; at least relative to our understanding.  With the help of Peter Loewen, we outline the anti-platelet options in secondary prevention of heart disease.  We discuss at length the use ASA and clopidogrel but also touch on additional agents like warfarin, dipyridamole and others.  Where the evidence is clear, we create opacity and where it is gray, we go dark. Both Mike and Peter end up in a quagmire and James offers them help by throwing them a string of one-liners and a bottle of low-dose ASA.

Show Notes

Secondary prevention with antiplatelets

1) ATTC Meta-analysis – aspirin in primary and secondary resistance

Lancet 2009;373:1849–60

2) CURE trial – clopidogrel added to aspirin

NEJM 2001;345:494-502

3) Anti-platelets in patients with a history of vascular disease or other predisposing condition – absolute benefit – 3.6% over 2 years (combined CVD events)

BMJ 2002;324:71-86

4) Low-dose aspirin – absolute benefit – around 3.3% combined CVD events and 1.5% mortality over 3 yrs

Am J Med 2008;121:43-9

5) CHARISMA – Clopidogrel and aspirin vs aspirin

N Engl J Med 2006; 354:1706-17

6) Half of the benefit of clopidogrel occurs in the first month of use Clopidogrel for the treatment of adult patients following acute coronary syndrome

Therapeutics Initiative Review

In episode 65, we start back at it with a discussion of using antiplatelets to decrease the chance of MIs and strokes. In this podcast, we cover the whole primary prevention aspect of these agents and we bring in our good friend and colleague Peter Loewen to help us with the numbers. Mike claims he, as a family doctor, is usually able to make a diagnosis of gender in his patients but refuses to do so in James’ case.

Show Notes

1) Primary Prevention with ASA (women and men)

JAMA 2006;295:306-13

ATTC 2009

Lancet 2009;373:1849–60

2) ASA in Type II diabetics (primary prevention)

POPADAD study

BMJ 2008;337:a1840

JPAD study

JAMA 2008;300:2134-41

PPP study

Diabetes Care 2003;26:3264-72

Canadian Diabetes Guideline (specifically, ASA)

Can J Diabet 2008;32:S102-06

3) Adding Clopidogrel to ASA in primary Prevention

CHARISMA Study (primary prevention sub-group)

NEJM 2006;354:1706-17

4) Peripheral vascular disease

Clopidogrel

CAPRIE

Lancet 1996;348:1329-39

5) Peter Loewen

peterloewen.com

Pharmacotherapy for ischemic stroke prevention