It was with particular interest that we read the study by Paul Barragan et al. on coronary artery stenting without anticoagulation, aspirin, ultrasound guidance, or high balloon pressure [1]. Dr. Barragan has to be credited for having routinely used ticlopidine instead of aspirin for all coronary angioplasty procedures since May 1986, and for proposing it as an alternative to oral anticoagulation by warfarin since he began implanting coronary stents in December 1989.
At that time, the then and still off-labeled indication of ticlopidine, combined with the provocative suppression of oral anticoagulants, was viewed with scepticism by most interventional cardiologists, including ourselves; and his first reports submitted to French and American cardiology journals were rejected. Catheterization and Cardiovascular Diagnosis was the first journal to accept for publication his preliminary study [2].
Use of ticlopidine after stenting was subsequently adopted by most European interventional cardiology centers, but this fact was disregarded-and emphasis was placed on high pressure stent dilatation and confirmation of adequate stent expansion by intravascular ultrasound [3]. The only randomized comparison of combined ticlopidine and aspirin therapy vs. aspirin therapy showed a 3-fold decrease (0.8% vs. 2.9%) in the ticlopidine treated group [4]. The difference was not statistically significant because of an insufficient number of patients, due to ''premature termination of the study before the expected target of 450 patients after the three deaths in the aspirin group.'' Surprisingly, the authors concluded that ''no definitive recommendations can be made regarding the superiority of ticlopidine and short-term aspirin compared with aspirin alone in the prevention of stent thrombosis.''
The French multicenter registry [5] showed that the ticlopidine/ aspirin combination allowed a low-cost stenting strategy without ultrasound assessment of stent deployment. The place of adjunctive IVUS in stenting remains controversial [6]. Therefore, when asking, ''Who was thrombogenic: the stent or the doctor?'' [7], someone was forgotten: the patient (and his drug regimen). Dr. Paul Barragan was also forgotten: In the randomized study comparing ticlopidine plus aspirin to anticoagulant therapy [8], his name was not even mentioned in the references. Very recently, a randomized clinical trial [9] has confirmed his view that the addition of aspirin seems to have no advantages over ticlopidine monotherapy in the poststenting medical treatment.
We believe that ticlopidine allowed coronary stents, a revolutionary progress in interventional cardiology, to be used safely in a growing number of patients.