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The Aspirin Plavix Combination in Stroke Prevention: Friend or Foe?

By April 14, 2009

The use of antiplatelet agents such as aspirin or clopidogrel (plavix) is an effective approach to stroke prevention. Sometimes, when people suffer a stroke while taking their aspirin regularly, they are deemed "aspirin failures", and some physicians argue that those patients should add a second antiplatelet agent to their regimen in order to prevent further strokes. But the evidence that this is a reasonable thing to do is lacking, and doing this, from a public health perspective, might even cause more harm than good.

At least this is what a recently published review of the literature on bleeding rates when aspirin and other anti-thrombotic agents are used together for secondary stroke prevention seems to imply. The study showed a significantly higher risk of bleeding when aspirin is used in combination with clopidogrel, or coumadin. The specific bleeding rates reported were as follows: 4.8% with aspirin alone, 2.9% with clopidogrel alone, 3.6% with aspirin plus aggrenox, but a whopping 10.1% with aspirin plus clopidogrel, and 16.8% with aspirin plus coumadin.

Major bleeding occurred at mean rates of 1% with aspirin alone, 0.85% with clopidogrel, but 1.7% with aspirin plus clopidogrel, and 2.5% with aspirin plus coumadin. And sadly this comes along without any added stroke protection when aspirin and plavix are used together. These numbers are concerning and should be considered strongly before aspirin and clopidogrel (plavix) are used for secondary stroke prevention.

That said, aspirin and plavix used together might help prevent some strokes, as shown by study published in the New England Journal of Medicine in which the combination of aspirin and clopidogrel decreased the risk of first strokes in people with atrial fibrillation who are unable to take coumadin for various reasons. Although the risk of bleeding was also greatly increased in that population as compared to those taking aspirin alone, the benefits of the combination of aspirin and clopidogrel might outweigh the risks.

Recommended reading:

Aspirin, Plavix, Side Effects
Atrial Fibrillation, Coumadin and Stroke Prevention
Six ways to Stay Stroke Free

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