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Antiplatelet therapy is a cornerstone in cardiovascular medicine. Aspirin and clopidogrel have emerged as critical therapies in the treatment of cardiovascular disease. Despite their efficacy, patients on these medications continue to suffer complications. Millions of patients are currently on low-dose antiplatelet therapy but it is unknown how many of these patients are under-treated or on the wrong medication. Clopidogrel hypo responsiveness or "resistance" is an emerging clinical entity with potentially severe consequences such as recurrent myocardial infarction, stroke, or death. The mechanism of resistance remains ill-defined, but there are specific clinical, cellular, and genetic factors that influence therapeutic failure. These factors range from physicians who fail to prescribe these medications despite appropriate indications to polymorphisms of platelet membrane glycoproteins. Rapid and accurate diagnosis of antiplatelet resistance also remains an issue as new bedside tests are developed. By understanding the mechanism of therapeutic failure and by improving the diagnosis of this clinical entity, a new era of individualized antiplatelet therapy may arise with routine measurements of platelet activity in the same way that cholesterol, blood pressure, and blood sugar are followed, thus improving the care for millions of people. This review article focuses on the mechanism of clopidogrel actions, available tools and mechanisms to assess and explain its responsiveness in addition to future management options.

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Diabetes is a major worldwide healthcare problem and cardiovascular diseases are the most common causes of mortality and morbidity in the type 2 diabetic population with Coronary artery disease (CAD) accounting for 65% to 80% of deaths in diabetic patients. It has been suggested that screening asymptomatic diabetics could identify early coronary artery disease which may improve their outcomes. In this review, we summarize the data regarding screening asymptomatic diabetics and provide recommendations based on the evidence.

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Objective: Clinical trials and practice guidelines have established the efficacy of early invasive strategy for high risk acute coronary syndrome (ACS) patients. This analysis was undertaken to detect the predictors of in-hospital cardiac catheterization (prior to hospital discharge) in patients with ACS in Kuwait and to assess if this use of early catheterization was according to published guidelines. Methods: We analyzed data from a prospective registry of 2054 consecutive patients admitted to all 7 general hospitals in Kuwait with the diagnosis of ACS over a period of 6 months in 2004. Results : Citizens were more likely to receive in-hospital catheterization than expatriates (52.1% vs 38.6%; odds ratio 1.7; 95% confidence interval [CI], 1.4 to 2.2; p < 0.001). Patients with recurrent ischemia were more likely to undergo in-hospital catheterization than patients without recurrent ischemia (55.9% vs 12.2%; odds ratio 11.2; 95% CI, 8.6 to 14.5; p < 0.001). Two coronary artery disease risk factors (hyperlipidemia and positive family history) were associated with high rate of in-hospital cardiac catheterization (respectively, odds ratio 1.3; 95% CI, 1.2 to 2; p < 0.001 and odds ratio 1.5; 95% CI, 1.3 to 2.3; p < 0.001). Conclusion: Although high risk patients benefit the most from an early invasive strategy after ACS, this strategy was persevered for those with recurrent ischemia and citizens. Other risk factors were not determinants for in-hospital cardiac catheterization. Thus, there is substantial opportunity to improve the use of this effective therapy in high risk patients.

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