Introduction
The major component in treatment and prevention of cardiovascular diseases is antiplatelet therapy. Traditionally aspirin has been used as a modality in the treatment and reduction of vascular events. Randomized controlled trials have been carried out to establish, if adding clopidogrel has any benefits. The results of such experiments have been very conflicting. Reasons for such conflicting results have been given as, population being heterogeneous. To establish the efficacy and safety of either dual therapy or monotherapy in reduction treatment of cardiovascular disease, metaanalysis of the controlled trial was carried out (Nursing, 2007).
Background question
IN PATIENTS WITH MIOCARDIAL INFARCTION AND CARDIOVASCULAR EVENTS IS ASPIRIN BENEFICIAL AS MONO OR DUAL THERAPY WITH CLOPIDOGREL?
P- Patients with Miocardialinfarction and Cardiovascular events
I-Clopidogrel plus Aspirin (dual therapy)
C- Antiplatelet Monotherapy
O- Reduction or prevention of vascular events
T- 8 months
Description of keywords and database used
Completed randomized controlled trials that investigated the effect of mono antiplatelet versus dual antiplatelet therapy in the prevention of vascular events in patients with vascular diseases were sought using medical subject headings and keywords related to aspirin and clopidogrel, cardiovascular disease (i.e., “unstable angina,” “ACS,” “myocardial infarction,” “stroke,” “percutaneous coronary intervention,” and “cerebrovascular disease”), and study type (i.e., “randomized controlled trial”) (White, 2008).
Appraisal of the article
The study properly addresses the given question. Comparing the efficacy of either dual therapy or monotherapy in the reduction of vascular events is the goal of the review (Nursing, 2007).
Another very critical issue is the description of the methodology used. Three studies each assessed patients with ACS and those who underwent PCI. All trials compared combined clopidogrel and aspirin with aspirin monotherapy, with the exception of the MATCH trial, which compared dual therapy with clopidogrel monotherapy (Miller, 2010).
This also included articles that
Reported safety outcomes, such as major bleeding.
Randomized tests which compared clopidogrel monotherapy or clopidogrel and aspirin with aspirin;
Considered efficacy outcomes that were clinically relevant, such as nonfatal or fatal re-infarction and all-cause mortality.
Based on search description of the methods used then this would qualify as level 1 evidence.
This review focuses on a maximum look on Embase and Medline (2006 to august 2009) as well as identifying the key journals in the subjects of study.
Heterogeneity was put in examination for each analysis in two forms
Inspection of OR visually
It was calculated and compared with a standard distribution
Overall results
These trials randomized 91,744 patients (45,868 to dual therapy with clopidogrel and aspirin and 45,874 to antiplatelet monotherapy). With 62 to 66.5 years, and the average proportion of men was 70%. There were a total of 5,033 deaths from all causes by the end of follow-up time (2,451 deaths in the combined aspirin and clopidogrel group and 2,582 in the antiplatelet monotherapy group) (Docherty, 2011).
TABLE
MONOTHERAPY
EER = # Events / # in Intervention Group
DUAL THERAPY CER = # Events / # in the control group
P
ARR = CER-EER
RRR = ARR/CER
RR = EER/CER
NNT = 1/ARR
ACS(CURE)
3219/30933 = 0.10
2862/30972 = 0.09
0.12
0.09-0.10 = -0.01
-0.01/0.10= -0.1
0.09/0.10= 0.9
1/ -0.01=-100
PCI(CURE)
403/3338 = 0.12
275/3359 = 0.08
0.48
0.08-0.12= -0.04
0.04/0.12 =0.3
0.08/0.12 = 0.6
1/0.04=25
Sub analysis
From the analysis we can draw conclusions that dual therapy can be used as an intervention in
prevention and treatment of vascular activity by reducing the risk of major bleeding hence
mortality (DiCenso, 2009).In an acute setting of practice the dual therapy as Nurse Practitioner
could be the best choice due to the less cases of re-infarction and death. The benefits with the
dual therapy is greater than the mono therapy and patients receiving aspirin plus clopidogrel
could avoid potential risk like death post infarction with the addition of clopidogrel as a classic
practice with monotherapy with ASA only.
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