Aggrenox (Boehringer Ingelheim, Ingelheim, Germany), a novel combination of low-dose
aspirin with
dipyridamole, represents a safe and promising combination alternative for mild but sustained platelet inhibition, and reduction of both arterial and venous thrombi occurrences. In a large, well-controlled randomized trial (ESPS-2 ) evaluating
antiplatelet agents for
stroke prevention,
Aggrenox was twice as effective as monotherapy with either
aspirin or
dipyridamole. There is an increasing body of evidence that a delicate strategy with
Aggrenox provides modest inhibition of platelet activity, especially in a chronic, long-term setting. Mild platelet inhibition beyond conventional aggregation may represent a substantial advantage over aggressive antiplatelet regimens for the treatment, and especially for
secondary prevention, of cerebrovascular ischemic events. Although there is no doubt that the concept of inhibiting platelets is vital for the treatment of vascular ischemic disease in general and
ischemic stroke and
transient ischemic attack (TIA) in particular, the optimal degree of such inhibition still remains an unsolved mystery. It seems that the concepts of "the more, the better" and "one size fits all" may no longer be valid for ideal antiplatelet protection in such high-risk populations. Without routine individual laboratory assessment of platelet function, mild regimens have the advantage of being more suitable for the majority of patients and will contribute substantially to the success of
dipyridamole. Conversely, if we can determine baseline platelet status and intelligently apply
therapy based on platelet activity in each particular patient, clinical outcomes may be better. Avoiding excessive
bleeding risks after aggressive strategies in patients with normal or already decreased platelet function, but targeting those who exhibit activated platelets, may improve risk stratification and save lives. Therefore,
Aggrenox should be considered a
drug of choice to prevent the second
stroke. Eliminating, or at least minimizing, the most frequent side effect, namely transitory
headaches at the beginning of
therapy with
Aggrenox, will benefit patients and increase the use of this agent. Should the PRoFESS (Prevention Regimen For Effectively avoiding Second
Strokes) trial show an advantage in event reduction with
Aggrenox over
clopidogrel, the increase will be especially dramatic. In short, based on current evidence most guidelines include
Aggrenox as a first-line option for
secondary prevention of
ischemic stroke or TIA, and some recent versions suggest it may be preferable in other clinical scenarios.