After undergoing coronary artery bypass grafting (CABG), a patient was sent home on clopidogrel (Plavix) but not aspirin. When he presented to the emergency department with acute coronary syndrome (ACS), he was not given aspirin at that time either, the emergency staff claiming that since he was on clopidogrel, he did not need aspirin. Is this correct?
—Harold Gottlieb, MD, Houston

I, too, am puzzled about the absence of aspirin in this case. Unless a patient is allergic to aspirin, there is no reason to omit it post CABG or when he has ACS. The drugs act by two different antiplatelet mechanisms and are considered complementary. The findings of randomized controlled trials (Clopidogrel in Unstable Angina to Prevent Recurrent Events [CURE], Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events [CAPRIE], and Clopidogrel for the Reduction of Events During Observation [CREDO]) in CAD patients have shown a substantial benefit for clopidogrel in conjunction with aspirin for the secondary prevention of cardiovascular events. Only in the Management of Atherothrombosis with Clopidogrel in High-Risk Patients with Recent Transient Ischaemic Attack or Ischaemic Stroke (MATCH) trial was use of the two agents not felt to be helpful, since the antistroke benefit was not statistically significant and the risk of life-threatening bleeding was increased (Lancet. 2004;364:331-337).
—Peter F. Cohn, MD (111-11)

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