If there's smoke, is there fire?

Abstract

As we read through the medical literature, we are always looking for the “hottest” new advances (jumping right into the smoke/fire analogy thing): basic science that gives us new mechanistic insights, clinical trials that confirm or reject our so-called insights, major new diagnostic and therapeutic options, and breakthrough technology. We are a lot like forest rangers, sitting up on a platform, way above the trees, looking out over the forest, and seeing something in the distance that looks like smoke. Then we have to decide if what we are seeing is really smoke coming from some forest-threatening fire, or if it is just fog in the trees. See p 1476 In the present issue of Circulation , Payne et al present a study1 showing that the addition of clopidogrel to aspirin significantly reduced the incidence of transcranial Doppler (TCD)–detected microemboli in patients after carotid endarterectomy (CEA). At face value, this makes intuitive sense. Given the importance of platelets and platelet emboli in postprocedural distal bed vascular injury (a lesson well learned in the coronary circulation), it seems logical to extend this to try to improve the outcomes of vascular manipulations in the cerebrovascular circulation. “Manipulation” may be a bit of an understatement when applied to a surgical procedure such as CEA, but the fact remains that there is room for improvement. Given the considerable benefits of aspirin plus thienopyridines in the world of percutaneous intervention in STent Antithrombotic Regimen Study (STARS)2 and the more recent Clopidogrel for Reduction of Events During Observation (CREDO)3 and Intracoronary Stenting and Antithrombotic Regimen–Rapid Early Action for Coronary Treatment (ISAR-REACT)4 studies, and in acute coronary syndromes in Clopidogrel in Unstable angina to prevent Recurrent ischemic Events (CURE),5 does this look to be a promising strategy for CEA? The study by …