Image credit: Getty/Alla Bielikova
New research has shown that switching to an anti-platelet drug called clopidogrel could reduce the risk of a heart attack, a stroke or death by 14% compared to taking aspirin, without increasing the risk of bleeding.
In the UK, around 45% of men and 34% of women over 65 take aspirin to prevent heart attacks and strokes. If you're one of them, should you swap to clopidogrel?
Both drugs reduce the chance of abnormal blood clotting in the arteries by stopping blood platelets sticking together to form blood clots.
A review of seven high-quality randomised controlled trials – where outcomes of people taking clopidogrel were compared to those taking aspirin – was published by international researchers from Switzerland, South Korea, the UK, USA and Italy in the Lancet Medical Journal.
The authors of the review said that the results “supported considering clopidogrel as the preferred long-term therapy in people with established coronary artery disease”.
It's estimated that around 38,850 people in England, Wales and Northern Ireland have a non-minor stroke annually, and 11 million clopidogrel items are dispensed each year.
“Aspirin reduces the stickiness of blood platelets, lowering the risk of blood clots in the arteries,” explains Dr Oliver Segal, consultant cardiologist and electrophysiologist at The Harley Street Clinic, part of HCA Healthcare UK.
“This helps prevent heart attacks and ischaemic strokes (where a blood clot blocks an artery supplying blood to the brain) in people who already have cardiovascular disease, and is known as secondary prevention.
“In the UK, the standard low dose is usually 75mg once daily (occasionally 100mg). This gives the protective effect without the higher bleeding risk of larger doses.”
Clopidogrel (brand names include Plavix and Grepid) is a prescription-only drug, so you will need to discuss it with your doctor.
“Recent large analyses show that for people with established coronary artery disease (such as those who've had a heart attack or a stent fitted), clopidogrel on its own may be slightly more effective than aspirin at preventing further heart attacks and strokes, without increasing major bleeding,” says Dr Segal.
It is, he says, already used in the UK, particularly after a stent has been inserted or for people who can’t tolerate aspirin. But nobody should switch without taking medical advice.
“It depends on personal risk, other medicines taken, and how well someone responds to clopidogrel,” Dr Segal explains.
Aspirin is unsuitable for some groups because of the risk of bleeding. These include:
Probably not immediately, as aspirin is cheap, effective and familiar. “For many people, [aspirin] will remain standard,” says Dr Segal.
“But for patients with known coronary disease, cardiologists are increasingly considering clopidogrel as an alternative.
“Over time, UK and European guidelines may shift towards greater use of clopidogrel in this group. However, not everyone responds equally well to clopidogrel due to genetic differences, and aspirin remains a safe option for many.”
“There has been long-standing interest in aspirin reducing the risk of bowel cancer if taken for many years,” continues Dr Segal.
“Some evidence supports this, but routine use purely for cancer prevention is not currently recommended by NICE (National Institute for Health and Care Excellence) because of bleeding risks. Aspirin is occasionally used for certain blood-clotting disorders, but always under specialist care.”
What are the key points to take away from the new research – and should everyone be taking aspirin?
“If you’ve had a heart attack or a stroke, or a stent inserted, an anti-platelet drug (aspirin or clopidogrel) is usually essential long-term,” says Dr Segal.
“If you’ve never had a cardiovascular event, aspirin is generally not advised, even if you have risk factors such as diabetes or high blood pressure. Those risks are better managed with cholesterol-lowering statins, blood pressure tablets and lifestyle changes.”
He says clopidogrel may well become more commonly used in secondary prevention, but for now, aspirin still has a major role to play.
“Always check with your GP before starting or stopping aspirin,” he stresses. “Decisions depend on your personal risk of heart disease versus your risk of bleeding.”
The Stroke Association has more information.
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