The Ideal Antiplatelet Drug for Stroke Prevention—Still Elusive

See related article, pages 1358–1363. Since the publication of the Antiplatelet Trialists Collaboration meta-analyses well over a decade ago1 showing a relative risk reduction of 25% from aspirin for all secondary vascular ischemic events in patients presenting with a variety of vascular disorders, there have been numerous attempts to improve on these modest benefits. Reducing the dose of aspirin reduced the risks of bleeding while maintaining therapeutic effectiveness,2 but using other antiplatelet drugs with different pharmacological actions such as ticlopidine, clopidogrel, or dipyrimadole have so far not produced any impresssive differences from those early data. The many attempts to pool the results of tens of thousands of patients using meta-analyses from the accumulating data of all these antiplatelet trials have also proven contentious. The problem with any meta-analysis is that the investigator must be selective, so introducing bias, but clearly should not include trials with obvious outdated methodology, incomplete data sets or where the patient cohort is so selective it can be generalized only to a minority of patients. This issue of Stroke includes a fresh attempt at an extensive meta-analysis of results from trials of the combination …