BMJ 1994;308:159-168 (15 January)

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Collaborative overview of randomised trials of antiplatelet therapy - II: Maintenance of vascular graft or arterial patency by antiplatelet therapy

,  Antiplatelet Trialists' Collaboration

Correspondence to: APT Statistical Secretariat, ICRF/BHF/MRC Clinical Trial Service Unit, Nuffield Department of Clinical Medicine, Radcliffe Infirmary, Oxford OX2 6HE, or APT Clinical Secretariat, Department of Clinical Neurosciences, Western General Hospital,Edinburgh EH4 2XU.

Abstract

Objective : To determine the efficacy of antiplatelet therapy in maintaining vascular patency in various categories of patients.
Design : Overviews of 46 randomised trials of antiplatelet therapy versus control and 14 randomised trials comparing one antiplatelet regimen with another.
Setting : Randomised trials that could have been available by March 1990 and in which vascular graft or arterial patency was to be studied systematically.
Subjects : About 8000 patients at varying degrees of risk of vascular occlusion (by virtue of disease or of having some vascular procedure) were in trials of antiplatelet therapy versus control and 4000 such patients were in trials directly comparing different antiplatelet regimens.
Results : Overall, antiplatelet therapy produced a highly significant (2P<0.00001) reduction in vascular occlusion, with similar proportional reductions in several different types of patient. Hence the absolute reductions tended to be largest among patients at highest risk of occlusion, with smaller but still significant absolute reductions among lower risk patients. The proportions of patients with confirmed occlusion among those allocated antiplatelet therapy versus appropriately adjusted control proportions (and mean scheduled treatment durations and net absolute benefits) were: (a) among about 4000 patients with coronary artery grafts, 21% antiplatelet therapy v 30% control (seven month benefit about 90 patients protected per 1000 allocated antiplatelet therapy (2P<0.00001); (b) among about 800 patients after coronary angioplasty, 4% antiplatelet therapy upsilion 8% control (six month benefit about 40/1000 (2P = 0.02)); (c) among about 3000 patients with peripheral artery procedures or disease, 16% antiplatelet therapy v 25% control (19 month benefit about 90/1000 (2P<0.00001); (d) among about 400 renal patients with a shunt or fistula placed for haemodialysis access, 17% antiplatelet therapy v 39% control (two month benefit about 200/1000 (2P<0.00001)).
Conclusion : Antiplatelet therapy (chiefly aspirin alone or aspirin plus dipyridamole) greatly reduces the risk of vascular occlusion in a wide range of patients at high risk of this complication. Further studies are required to determine exactly when treatment should start (to limit any perioperative bleeding while still preventing most early occlusion) and for how long it should be continued.

Clinical implications

  • Clinical implications

  • Patients who have undergone coronary artery bypass grafting or angioplasty or leg artery bypass grafting or angioplasty are at high risk of both major clinical "vascular events" (myocardial infarction, stroke, or vascular death) and subclinical vascular occlusions

  • As well as preventing about one quarter of clinical vascular events in patients undergoing such vascular procedures, antiplatelet therapy also reduced the odds of vascular graft or arterial occlusion by about 40% while treatment continued

  • Typically, among 1000 patients who have coronary artery revascularisation procedures, about six months of antiplatelet therapy should prevent several dozen patients from having coronary artery occlusion as well as a few dozen major clinical vascular events

  • Patients who have peripheral artery revascularisation procedures tend to be at lower risk of vascular events, but even so about one or two years of antiplatelet therapy in 1000 such patients should not only prevent several dozen from having peripheral artery occlusion but also avoid several major vascular events

  • Antiplatelet therapy also substantially reduced the rate of occlusion of arteriovenous fistulas or shunts established for haemodialysis access (and should also reduce the high incidence of major vascular events in such patients)


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