Treating coronary artery disease in patients with a history of cerebrovascular disease.

Patients with coronary artery disease and a history of stroke account for as many as one in eight of all patients with coronary artery disease, and they are at higher risk of ischaemic events than patients with 'lone' coronary artery disease. It is therefore tempting to increase the potency of antithrombotic treatment in this patient subset. However, these patients are also at greater risk of intracranial haemorrhage. In recent trials of new antithrombotic agents in acute coronary syndromes, patients with a history of cerebrovascular disease derived no clinical benefit from (and were even harmed by) the potent novel antithrombotic agents, with an increased risk of intracranial haemorrhage. However, this risk did not appear to be uniform: it was higher in patients with a history of stroke than in those with a history of transient ischaemic attack, and appeared to be largely confined to the first year after stroke/transient ischaemic attack. Specific strategies to optimize the benefit/risk ratio of antithrombotic agents in this relatively common patient group should be developed and evaluated.