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BMJ. 2007 May 19; 334(7602): 1020.
PMCID: PMC1871757
Dipyridamole with Aspirin

Combination shows no advantage over aspirin alone

Manfred Gogol, head, geriatric department

I disagree with Sudlow's recommendations.1 The cited ESPRIT study had lots of limitations. Firstly, during the study inclusion criteria changed from a three arm to a two arm design.2 3 Secondly, patients and physicians were not blinded to the treatment regimen. The resulting confounder therefore cannot be estimated. Thirdly, possible lifestyle changes, comorbidity, and co-treatment were not under examination.

Adherence in the dipyridamole-aspirin group was much less (2.6-fold) than in the aspirin group. The on-treatment analysis showed only a small benefit for bleeding complications (hazard ratio 0.58, 95% confidence interval 0.35 to 0.97). The analysis by intention to treat showed small benefits only in combined end points, which was driven by the single benefit in the occurrence of non-fatal strokes. The combined treatment showed no advantage in death. The new occurrence of disability was not reported. Furthermore, the real benefit from a number needed to treat of 104 is small.4

In my view the published data of ESPRIT do not alter the recommendations of the Antithrombotic Trialists' Collaboration.5

Notes

Competing interests: None declared.

References

1. Sudlow C. Give dipyridamole with aspirin instead of aspirin alone to prevent vascular events after ischaemic stroke or TIA. BMJ 2007;334:901 (28 April.) [PMC free article] [PubMed]
2. De Schryver ELLM, on behalf of the European/Australian stroke prevention in reversible ischaemia trial (ESPRIT) group. Design of ESPRIT: an international randomized trial for secondary prevention after non-disabling cerebral ischaemia of arterial origin. Cerebrovasc Dis 2000;10:147-50. [PubMed]
3. De Schryver ELLM. ESPRIT: Protocol changes. Cerebrovasc Dis 2001;11:286. [PubMed]
4. Tirschwell D. Aspirin plus dipyridamole was more effective than aspirin alone for preventing vascular events after minor cerebral ischemia. ACP Journal Club November/December 2006;145:57.
5. Antithrombotic Trialists' Collaboration. Collaborative meta- analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002;324:71-86. [PMC free article] [PubMed]

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