Antithrombotic Agents in Coronary Artery Disease

Aspirin as a therapeutic agent in cardiovascular disease. Special Writing Group.

“…After patients have survived a year, reinfarction and death rates, stabilized at 3-5% per year, are similar to those of patients with symptomatic coronary artery disease (i.e., angina pectoris) but significantly greater than those of the general population. 1 Coronary mural thrombosis and its fibrotic organization contributing to the atherosclerotic process was suggested by von Rokitansky2 in the mid-19th century and later by Duguid3 in the 1940s. Indeed, more recent technology-angiographic, angioscopic, pathological, and experimentalhas documented that disruption of small plateletand fibrin-rich atherosclerotic plaques, with subsequent mural thrombosis and fibrotic organization of the thrombus, may contribute to the progression of coronary atherosclerosis.4'5 However, it is not known how prevalent this process of intermittent plaque progression is compared with the more chronically progressive proliferative process secondary to chronic endothelial irritation postulated by Ross.6 Nevertheless, it would be of potential clinical significance if mural thrombosis could be decreased by platelet inhibitor or anticoagulant therapy.…”

“…Except for aspirin, which was started 12 hours preoperatively, therapy was initiated 48 hours before surgery. Early graft patency at a median of 9 days was significantly higher in the aspirin-treated groups (92%) than in those given placebo (85%).105 At 1 year benefit was seen only in patients at high risk of graft occlusion (those with vein grafts placed to vessels <1.5 mm in diameter) taking aspirin.157 It is important to note that one daily dose of aspirin was as effective as aspirin given three times daily. Dipyridamole conferred no additional benefit over aspirin alone.…”

Guide to anticoagulant therapy. Part 2: Oral anticoagulants. American Heart Association.

“…Oral anticoagulant therapy during a 1to 6-year treatment period reduced the combined incidence of mortality and nonfatal reinfarction by approximately 20%. 68,69,78 The value of oral anticoagulants in the long-term treatment of myocardial infarction is supported by the results of two studies66,67 ( Table 8). The Sixty-Plus Reinfarction Study Group limited their subject population to patients over the age of 60 who had been treated with oral anticoagulants for at least 6 months.…”

“…The rate of oral anticoagulantinduced bleeding is increased by the concomitant use of high doses of aspirin, which both impair platelet function and produce gastric erosions.32,33 The risk of bleeding is increased in those who are more than 65 years old, have a history of stroke or gastrointestinal bleeding, or serious comorbid conditions such as renal insufficiency or anemia. 78,97 Bleeding that occurs when the INR is less than 3.0 is frequently associated with an obvious underlying cause or an occult gastrointestinal or renal lesion. 98 …”

Guidelines for the management of transient ischemic attacks. From the Ad Hoc Committee on Guidelines for the Management of Transient Ischemic Attacks of the Stroke Council of the American Heart Association.

“…104 There is general agreement that most patients with stroke due to cardiac embolism should be given anticoagulation therapy. This practice is based on extrapolation from level I evidence from primary prevention studies in atrial fibrillation 133134 and coronary artery disease, 135 as well as level III and IV evidence from a number of studies of secondary prevention. Until recently no prospective trial had specifically examined cardioembolic TIAs.…”