Dear Editor, We have read the findings by Monesi et al. in the Journal on the appropriateness of antiplatelet therapies in a large cross-sectional study in Italy [1]. Not surprisingly, they found low use of antiplatelets for primary and secondary prevention. We have a few comments and questions regarding their paper. The authors do not mention specifically how the drug treatments were collected. Were patients questioned by their doctors at the time of study, or were the data obtained from pharmacies? We are also curious as to why patients with atrial fibrillation were excluded from this study. Although we agree that most patients should be considered for antithrombotic therapy (i.e., warfarin), there are sufficient data to support the use of aspirin in individuals with atrial fibrillation who are at fairly low absolute risk of stroke or who have contraindications to warfarin [2]. Furthermore, the authors did not show which other medications the patients were receiving that may have made low-dose aspirin inappropriate (for instance, warfarin for deep vein thrombosis prophylaxis, current nonsteroidal antiinflammatory or prednisolone use, and so on). It is also unfortunate that data on contraindications, previous use, allergy, intolerance, or deliberate noncompliance with aspirin were not collected, as it is well known that patients become nonadherent to therapies, particularly for primary prevention. For example, in Morant et al.'s observational study of more than 17,000 new aspirin users, only 47% were compliant with therapy after 2.5 years [3]. We believe that the study is weakened by the failure to collect data such as contraindications to low-dose aspirin. Moreover, how fair is it to state that there is underuse of aspirin from data collected in 2000, yet classify 10-year risk using a model (SCORE) that was published in 2003? In addition, the data were collected before recommendations for the use of aspirin for primary prevention were made by authoritative groups such as the United States Preventive Services Task Force [4], and current practice is likely to have improved. In particular, the benefit of prophylactic aspirin in populations such as diabetics, the elderly, and women were not well established when the data were collected; therefore, the results might just reflect prescribers’ concerns or doubts at that time about who should and should not receive aspirin. It would be interesting to know whether any national Italian guidelines prior to and at the time of data collection were available to prescribers for the use of aspirin in primary prevention, as the results from the two cited studies [5, 6] that demonstrated the benefit of aspirin for primary prevention were unlikely to have reached the majority of prescribers. If there were no guidelines for prescribers, then the results of this study only indicate a need for a national guideline to be distributed and implemented. We also believe these findings suggest that many patients are inappropriately started on antiplatelet medications for primary prevention. For example, 40% of patients (Table 3 in the paper) were receiving antiplatelet therapy but had a 10-year fatal cardiovascular disease risk of 6%. The American Heart Association’s guidelines [7] also recommend the use of aspirin in persons at high risk for coronary vascular disease, but use a 10% risk per 10 years. This suggests to us that the wrong people are receiving aspirin, with as many as one in three receiving aspirin without adequate justification. In summary, we suggest that the data presented by Monesi et al. not only show underuse of antiplatelets in 2000 but demonstrate inappropriate use of aspirin, which may mean there is more net harm than benefit. Despite our criticisms, we believe this sort of research is important and worthwhile in improving prescribing practice and patient care. M. Naunton (*) Department of Pharmacotherapy and Pharmaceutical Care, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands e-mail: M.Naunton@rug.nl Tel.: +31-50-3637576 Fax: +31-50-3632772