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Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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Psychogios M, Brehm A, López-Cancio E, Marco De Marchis G, Meseguer E, Katsanos AH, Kremer C, Sporns P, Zedde M, Kobayashi A, Caroff J, Bos D, Lémeret S, Lal A, Arenillas JF. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease. Eur Stroke J 2022; 7:III-IV. [PMID: 36082254 PMCID: PMC9446330 DOI: 10.1177/23969873221099715] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/22/2022] [Indexed: 07/22/2023] Open
Abstract
The aim of the present European Stroke Organisation guideline is to provide clinically useful evidence-based recommendations on the management of patients with intracranial atherosclerotic disease (ICAD). The guidelines were prepared following the Standard Operational Procedure of the European Stroke Organisation guidelines and according to GRADE methodology. ICAD represents a major cause of ischemic stroke worldwide, and patients affected by this condition are exposed to a high risk for future strokes and other major cardiovascular events, despite best medical therapy available. We identified 11 relevant clinical problems affecting ICAD patients and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions. The first two questions refer to the asymptomatic stage of the disease, which is being increasingly detected thanks to the routine use of noninvasive vascular imaging. We were not able to provide evidence-based recommendations regarding the optimal detection strategy and management of asymptomatic ICAD, and further research in the field is encouraged as subclinical ICAD may represent a big opportunity to improve primary stroke prevention. The second block of PICOs (3-5) is dedicated to the management of acute large vessel occlusion (LVO) ischemic stroke caused by ICAD, a clinical presentation of this disease that is becoming increasingly relevant and problematic, since it is associated with more refractory endovascular reperfusion procedures. An operational definition of probable ICAD-related LVO is proposed in the guideline. Despite the challenging context, no dedicated randomized clinical trials (RCTs) were identified, and therefore the guideline can only provide with suggestions derived from observational studies and our expert consensus, such as the escalated use of glycoprotein IIb-IIIa inhibitors and angioplasty/stenting in cases of refractory thrombectomies due to underlying ICAD. The last block of PICOs is devoted to the secondary prevention of patients with symptomatic ICAD. Moderate-level evidence was found to recommend against the use of oral anticoagulation as preferred antithrombotic drug, in favor of antiplatelets. Low-level evidence based our recommendation in favor of double antiplatelet as the antithrombotic treatment of choice in symptomatic ICAD patients, which we suggest to maintain during 90 days as per our expert consensus. Endovascular therapy with intracranial angioplasty and or stenting is not recommended as a treatment of first choice in high-grade symptomatic ICAD (moderate-level evidence). Regarding neurosurgical interventions, the available evidence does not support their use as front line therapies in patients with high-grade ICAD. There is not enough evidence as to provide any specific recommendation regarding the use of remote ischemic conditioning in ICAD patients, and further RCTs are needed to shed light on the utility of this promising therapy. Finally, we dedicate the last PICO to the importance of aggressive vascular risk factor management in ICAD, although the evidence derived from RCTs specifically addressing this question is still scarce.
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Affiliation(s)
- Marios Psychogios
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
| | - Elena López-Cancio
- Department of Neurology, Hospital
Universitario Central de Asturias, Oviedo, Spain
| | - Gian Marco De Marchis
- Department of Neurology and Stroke
Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Elena Meseguer
- Department of Neurology and Stroke
Center, Assistance Publique Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Aristeidis H Katsanos
- Division of Neurology, McMaster
University and Population Health Research Institute, Hamilton, ON, Canada
| | - Christine Kremer
- Department of Neurology, Skåne
University Hospital, Malmö, Department of Clinical Sciences Lund University, Lund,
Sweden
| | - Peter Sporns
- Department of Neuroradiology,
University Hospital Basel, Basel, Switzerland
- Department of Neuroradiology,
University Clinic Hamburg Eppendorf, Hamburg, Germany
| | - Marialuisa Zedde
- Neurology Unit, Department of
Neuromotor Physiology, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio
Emilia, Italy
- Neurology Unit, Stroke Unit, Azienda
Unità Sanitaria Locale-IRCCS di Reggio Emilia, Italy
| | - Adam Kobayashi
- Department of Pharmacology and
Clinical Pharmacology, Institute of Medical Sciences, Faculty of Medicine –
Collegium Medicum Cardinal Stefan Wyszynski University in Warsaw, Poland
- Department of Neurology and Stroke
Unit, Mazovian Voivodeship Hospital in Siedlce, Poland
| | - Jildaz Caroff
- Department of Interventional
Neuroradiology – NEURI Brain Vascular Center, Bicêtre Hospital, Assistance Publique
Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Daniel Bos
- Department of Radiology and Nuclear
Medicine, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus
MC, Rotterdam, The Netherlands
| | | | - Avtar Lal
- European Stroke Organisation, Basel,
Switzerland
| | - Juan F Arenillas
- Stroke Program, Department of
Neurology, Hospital Clínico Universitario de Valladolid, Spain
- Clinical Neurosciences Research
Group, Department of Medicine, University of Valladolid, Spain
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Sagris D, Georgiopoulos G, Leventis I, Pateras K, Pearce LA, Korompoki E, Makaritsis K, Vemmos K, Milionis H, Ntaios G. Antithrombotic treatment in patients with stroke and supracardiac atherosclerosis. Neurology 2020; 95:e499-e507. [PMID: 32631920 DOI: 10.1212/wnl.0000000000009823] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/09/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety of oral anticoagulants vs antiplatelets in patients with stroke and atherosclerotic plaques in the aortic arch or cervical or intracranial arteries, collectively described as supracardiac atherosclerosis. METHODS We searched PubMed and Scopus until August 28, 2019, for randomized trials comparing oral anticoagulants vs antiplatelets in patients with stroke and supracardiac atherosclerosis using the terms "anticoagulant or anticoagulation" and "antiplatelet or aspirin" and "randomized controlled trial or RCT" and "stroke or cerebral ischemia" and "aortic or carotid or vertebrobasilar or intracranial or atherosclerosis or stenosis or arterial." Four outcomes were assessed: recurrent ischemic stroke, major ischemic event or death, major bleeding, and intracranial bleeding. Treatment effects (relative risk [RR] and 95% confidence interval [CI]) were estimated by meta-analysis using random-effects models. RESULTS Among 1,117 articles identified in the literature search, results from 10 randomized controlled trials involving 6,068 patients with stroke/TIA with supracardiac atherosclerosis were included in the meta-analysis. Recurrent ischemic stroke rates were 2.94 per 100 patient-years in the anticoagulant-assigned patients vs 3.30 per 100 patient-years in the antiplatelet-assigned patients (RR, 0.91; 95% CI, 0.70-1.18 for the SJ estimator, I2 = 26%). Major ischemic event or death rates were 4.39 per 100 patient-years in anticoagulant-assigned patients vs 4.32 in antiplatelet-assigned patients (RR, 1.03; 95% CI, 0.79-1.35; I2 = 54.5%). Major bleeding rates were 2.88 per 100 patient-years in anticoagulant-assigned patients vs 0.82 in antiplatelet-assigned patients (RR, 3.21; 95% CI, 1.96-5.24; I2 = 46%). CONCLUSION This systematic review and meta-analysis showed that anticoagulant-assigned patients with stroke and supracardiac atherosclerosis were not at different risk of ischemic stroke recurrence and increased risk of major bleeding compared to antiplatelet-assigned patients.
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Affiliation(s)
- Dimitrios Sagris
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Georgios Georgiopoulos
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Ioannis Leventis
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Konstantinos Pateras
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Lesly A Pearce
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Eleni Korompoki
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Konstantinos Makaritsis
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Konstantinos Vemmos
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - Haralampos Milionis
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece
| | - George Ntaios
- From the Department of Internal Medicine (D.S., I.L., K.M., G.N.), Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College, London, UK; Department of Biostatistics and Research Support (K.P.), Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands; biostatistics consultant (L.A.P.), Minot, ND; Department of Clinical Therapeutics (E.K., K.V.), Alexandra Hospital, University of Athens, Greece; Imperial College London (E.K.), UK; and Department of Internal Medicine, School of Medicine (H.M.), University of Ioannina, Greece.
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