Platelets are the major culprits in initiating arterial thrombus.Platelet inhibition is the key modality to treat /prevent acute and chronic coronary syndromes. It is an approved indication for primary and secondary prevention of CAD.
Anti platelet agents are the biggest drug market among the cardiac drugs. It is a billion dollar medical game played with two million human platelets !
Aspirin is the best anti-platelet agent known .It is not only most effective but also available at a fraction of the cost other drugs. Unfortunately it is a generic and not a patented one .Being cheap , good safety profile is the biggest disadvantage of aspirin ! So , consistent efforts were made to make this drug appear weaker. Hence came many new anti-platelet agents .
After analyzing the available literature , I have compiled the following conclusions ( Mostly biased observation ! but I strongly believe the bias is more towards truth . . . )
All of the following statements can be termed either true ,were true , believed to be true , may be true , at some point of time (Between the last decade and today !)
- Aspirin alone is good enough in both ACS and chronic CAD
- Clopidogrel is equally effective like aspirin in ACS.
- Aspirin alone is dangerous in ACS.
- Clopidogrel alone is more dangerous than aspirin alone in ACS,
- Aspirin + Clopidogrel provides the best anti-platelet action.
- Aspirin + Clopidogrel combination is still dangerous .
- Prasugrel is more effective than clopidogrel
- Prasugrel can never be as effective as aspirin *
- Never use clopidogrel alone in DES patient.
- Aspirin can be safe in most stented patients
- Mono platelet inhibition is a crime !
- Risk of sudden death continues to be significant in spite of dual antiplatelet agents in many with DES.
- For prasugrel to be really useful it should always be prescribed with aspirin.
- Prasugrel alone can be dangerous in stented patients.
- If the patient is getting heparin simultaneously none of the above seems to be really important (Of course all patients with ACS will be getting this )
Above are my inferences in all those trials on platelets in the last three decades
What do you infer ?
To a discerned reader all of the above statements may appear wrong !
*Finally , it looks to me both clopidogrel and prasugrel ride a fake ride on the shoulders of trusted war horse called Aspirin . There is a strong basis for this suspicion as none of the researchers are ready to do a one to one direct comparison between aspirin and prasugrel or clopidogrel !