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(Stroke. 2007;38:1142.)
© 2007 American Heart Association, Inc.

Letters to the Editor

Emerging Therapies: ESPRIT

Department of Neurology, Division of Cerebrovascular Diseases & Neurocritical Care, Columbia University Medical Center, New York, NY

An extract of the first 250 words of the full text is provided, because this article has no abstract.

To the Editor:

It was with great anticipation and interest that I read the ESPRIT results¹ and the accompanying Editorial in Stroke.² The study reports superiority of aspirin plus dipyridamole over aspirin alone in patients with minor or transient cerebral ischemic symptoms, for the composite outcome of vascular mortality, cerebrovascular event, myocardial infarction, and major hemorrhage.¹ In reviewing the outcome measure details, several concerns arose regarding the interpretation of this study by the authors and by the editorialist.

In recent cardiovascular trials, a beneficial effect of combination antiplatelet therapy for preventing myocardial ischemia greatly contributed to the benefit seen for cumulative vascular outcomes.^3–5 Similarly, in ESPS-2 an overall benefit for the cumulative outcome was largely driven by the impact of aspirin plus extended-release dipyridamole in preventing cerebral ischemia.⁶ Unlike these studies, ESPRIT demonstrated no benefit for any primary ischemic outcome, including cardiac, cerebral, or all ischemic events.¹ Being that antiplatelet therapy is primarily designed to prevent or reduce thrombosis, one must question then whether ESPRIT was truly a "positive" study.

The only end points in ESPRIT that did demonstrate superiority for combination therapy were those that allowed for the incorporation of hemorrhages into the outcome measure vis-à-vis vascular mortality, nonfatal cerebrovascular events, and nonfatal major hemorrhages.¹ Given the discrepancy in major hemorrhages (which included fatal and intracranial episodes) between the combination and aspirin alone treatment groups (2.57% versus 3.85%, hazard ratio=.67, 95% CI=0.44 to 1.03),¹ the positive findings of ESPRIT may have been partially driven by this imbalance in . . . [Full Text of this Article]