Dual antiplatelet therapy in high-risk patients

The use of antiplatelet monotherapy as part of treatment regimens for high-risk patients with thrombotic disease results in significant reductions in ischaemic outcomes. Numerous studies have highlighted the benefits of antiplatelet monotherapy, including the 2002 meta-analysis by the Antiplatelet Trialists' Collaboration. Aspirin was the most commonly studied agent in this analysis and, while it remains the mainstay of antiplatelet therapy for reducing the risk of cardiovascular events, it is associated with significant residual cardiovascular risk. There is, however, a growing body of evidence demonstrating that combining aspirin with other antiplatelet agents with different mechanisms of action further improves long-term clinical outcomes both in stroke patients and in patients with acute coronary syndromes. Despite the evidence from clinical trials and guidelines supporting the use of additional antiplatelet therapies in high-risk patients, several large-scale studies (GRACE, Euroheart survey, REACH) have shown that antiplatelet therapies remain significantly underused. Improved physician education and the availability of new antiplatelet treatment options that potentially overcome some of the limitations of existing agents may increase the implementation of antiplatelet guidelines and the use of combination antiplatelet therapy.