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(Stroke. 2000;31:983-a.)
© 2000 American Heart Association, Inc.

Letters to the Editor

Supplement to the AHA Guidelines for the Management of Transient Ischemic Attacks

Richard L. Hughes, MD

University of Colorado School of Medicine, Denver, Colorado

To the Editor:

I must respectfully disagree with the recent AHA Scientific Statement on the management of transient ischemic attacks.¹

First, the inclusion of the combination antiplatelet agent extended release dipyridamole and aspirin (ERDP/ASA) as a "recommended therapy" is premature. The current data are insufficient to definitively establish that ERDP/ASA offers anything in addition to aspirin alone. Although the results of the ESPS-2 trial² of ERDP/ASA are encouraging and generate great optimism for this and other combination strategies, serious questions remain. The ESPS-2 results are highly inconsistent with previous data on 5317 patients treated with the combination.³ Although a heterogeneous set of trials, these data were sufficient to all but abandon use of dipyridamole in the 1980s. Further, the high rate of subject dropout,² the lack of any benefit in vascular death despite the stunning benefit in stroke,² the 50-mg dose of ASA,^{2 4} and the scientific misconduct⁵ discovered in the trial collectively make ESPS-2 inadequate to certify ERDP/ASA as an established therapy by the AHA or any other body.⁶ Any new scientific finding that is a large departure from previous data or theory requires independent conformation. Such is true of ERDP/ASA.

Second, a variety of commonly used antithrombotic strategies deserve mention with ERDP/ASA as potentially useful, if unproven, alternatives. This includes the use of clopidogrel or ticlopidine with aspirin,^{7 8 9} a well-accepted standard for poststenting prophylaxis. For some warfarin patients, the addition of any antiplatelet agent can help also.^{10 11} Further, for those who are impressed with the dramatic ESPS-2 results of . . . [Full Text of this Article]

Gregory W. Albers, , MD

Stanford Stroke Center, Stanford University School of Medicine, Palo Alto, California

Robert G. Hart, MD

Department of Medicine/Neurology, The University of Texas Health Science Center at San Antonio

Helmi L. Lutsep, MD

Oregon Stroke Center, Oregon Health Sciences University, Portland, Oregon

David W. Newell, MD

Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington

Ralph L. Sacco, MD

Neurological Institute, Columbia–Presbyterian Medical Center, New York, NY