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Venketasubramanian N, Agustin SJ, Padilla JL, Yumul MP, Sum C, Lee SH, Ponnudurai K, Gan RN. Comparison of Different Laboratory Tests to Identify “Aspirin Resistance” and Risk of Vascular Events among Ischaemic Stroke Patients: A Double-Blind Study. J Cardiovasc Dev Dis 2022; 9:jcdd9050156. [PMID: 35621867 PMCID: PMC9145610 DOI: 10.3390/jcdd9050156] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/07/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022] Open
Abstract
“Aspirin resistance” (AR) is associated with increased risk of vascular events. We aimed to compare different platelet function tests used in identifying AR and assess their implications on clinical outcome. We performed platelet aggregation studies on non-cardioembolic ischaemic stroke patients taking aspirin 100 mg/day and 30 non-stroke controls. Data were collected on demographics, vascular risk factors, and concomitant medications. Cut-offs for AR were (1) light transmission aggregometry (LTA) of ≥20% using arachidonic acid (AA), ≥70% using ADP, or ≥60% using collagen; and (2) VerifyNow® assay ≥ 550 ARU. Telephone follow-ups were conducted by study staff blinded to AR status to ascertain the occurrence of vascular outcomes (stroke, myocardial infarction, amputation, death). A total of 113 patients were recruited, mean age 65 ± 8 years, 47% women, 45 ± 15 days from index stroke. 50 (44.3%, 95% CI 34.9–53.9) had AR on at least 1 test. Frequency of AR varied from 0% to 39% depending on method used and first vs. recurrent stroke. There were strong correlations between LTA AA, VerifyNow® and Multiplate® ASPItest (r = 0.7457–0.8893), but fair to poor correlation between LTA collagen and Multiplate® COLtest (r = 0.5887) and between LTA ADP and Multiplate® ADPtest (r = 0.0899). Of 103 patients with a mean follow up of 801 ± 249 days, 10 (9.7%) had vascular outcomes, of which six had AR by LTA-ADP. AR by LTA-ADP is associated with increased risk of vascular outcome (p = 0.034). Identification of AR is not consistent across different platelet function tests. LTA of ≥70% using 10 µM ADP in post-stroke patients taking aspirin is associated with increased risk of vascular outcome.
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Affiliation(s)
| | - Sherwin Joy Agustin
- Research Department, National Neuroscience Institute, Singapore 188770, Singapore;
| | - Jorge L. Padilla
- Department of Medicine, Cotabato Regional and Medical Center, Cotabato 9600, Philippines;
| | - Maricar P. Yumul
- Department of Neurology and Psychiatry, University of Santo Tomas Hospital, Manila 1015, Philippines;
| | - Christina Sum
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore 188770, Singapore; (C.S.); (K.P.)
| | - Sze Haur Lee
- Department of Neurology, National Neuroscience Institute, Tan Tock Seng Campus, Singapore 188770, Singapore;
| | - Kuperan Ponnudurai
- Department of Laboratory Medicine, Tan Tock Seng Hospital, Singapore 188770, Singapore; (C.S.); (K.P.)
| | - Robert N. Gan
- Medical Affairs, Moleac Singapore, Pte Ltd., Singapore 188770, Singapore;
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Javalkar V, Kuybu O, Amireh A, Kelley RE. Evolving Approaches to Antithrombotics in Stroke Prevention and Treatment. South Med J 2020; 113:585-592. [PMID: 33140113 DOI: 10.14423/smj.0000000000001173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The optimization of antithrombotic therapy for acute stroke treatment and secondary prevention is an evolving process based on an increasing array of studies that provide an evidence-based approach. Options have increased dramatically with the release of the non-vitamin K oral anticoagulants and with the results of recent randomized clinical trials designed to assess potential benefits versus risks for patients in an individualized fashion. Recent studies have provided important information to guide choice and dosing of antiplatelet agents as well as the length of treatment. Anticoagulant use is particularly pertinent for stroke prevention in patients at higher risk of atrial fibrillation and may have a place in certain other stroke mechanisms. One important focus of study is the potential benefit of combined antiplatelet and anticoagulant therapy. Options for our patients, when the initial choice of therapy does not demonstrate benefit or is not well tolerated, clearly, are valuable. For example, short-term dual antiplatelet therapy for minor stroke and transient ischemic attack is being adopted, but with the recognition that longer-term combined therapy is not worth the increased risk of bleeding. Alternative antiplatelet choices, such as cilostazol and possibly ticagrelor, may be of benefit for refractory patients and this could affect the decision-making process. This review represents an effort to incorporate the information from more recent stroke prevention and treatment studies with information gleaned from prior studies.
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Affiliation(s)
| | - Okkes Kuybu
- From the Department of Neurology, Louisiana State University Health, Shreveport
| | - Abdallah Amireh
- From the Department of Neurology, Louisiana State University Health, Shreveport
| | - Roger E Kelley
- From the Department of Neurology, Louisiana State University Health, Shreveport
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Yi X, Lin J, Wang C, Huang R, Han Z, Li J. Platelet function-guided modification in antiplatelet therapy after acute ischemic stroke is associated with clinical outcomes in patients with aspirin nonresponse. Oncotarget 2017; 8:106258-106269. [PMID: 29290946 PMCID: PMC5739731 DOI: 10.18632/oncotarget.22293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 10/25/2017] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To investigate the association of clinical outcomes with platelet function-guided modification in antiplatelet therapy in patients with ischemic stroke. RESULTS Among 812 patients, 223 patients had aspirin nonresponse, 204 patients was modified in antiplatelet therapy after platelet function testing. Mean follow-up period was 4.8 ± 1.7 years (ranged from 1 to 6.4 years). The incidence rates of ischemic events, death, or bleeding events were not significantly different between the patients with and without antiplatelet therapy modification. However, in patients with aspirin nonresponse, antiplatelet therapy modification was associated with decreased ischemic events (hazard ratio, 0.67; 95% confidence interval [CI], 0.62-0.97; P = 0.01) and ischemic stroke (hazard ratio, 0.70; 95% CI, 0.63-0.98; P = 0.03) compared with no modification in antiplatelet therapy. CONCLUSIONS In patients with aspirin nonresponse, platelet function-guided modification in antiplatelet therapy after an ischemic stroke was associated with significantly lower rate of ischemic events. The platelet function testing may be useful to guide antiplatelet therapy modification. METHODS This is a retrospective, multicentre study. From August 2010 to December 2014, 812 patients with ischemic stroke underwent platelet function testing using platelet aggregation. Antiplatelet therapy modification was defined as any change in antiplatelet therapy after testing, including increasing aspirin dosage, adding an additional antiplatelet agent to aspirin, or switching to a more potent antiplatelet agent. The primary outcome was ischemic events. Secondary outcomes included death and bleeding events. Clinical outcomes were compared between patients with and without antiplatelet therapy modification using univariate and propensity score-adjusted analyses.
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Affiliation(s)
- Xingyang Yi
- Department of Neurology, People’s Hospital of Deyang City, Deyang 618000, Sichuan, China
| | - Jing Lin
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou 325200, Zhejiang, China
| | - Chun Wang
- Department of Neurology, People’s Hospital of Deyang City, Deyang 618000, Sichuan, China
| | - Ruyue Huang
- Department of Neurology, The Third Affiliated Hospital of Wenzhou Medical University, Wenzhou 325200, Zhejiang, China
| | - Zhao Han
- Department of Neurology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou 325027, Zhejiang, China
| | - Jie Li
- Department of Neurology, People’s Hospital of Deyang City, Deyang 618000, Sichuan, China
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Overbeck U, Endres HG, Krogias C, Neubauer H, Meves SH. Dose-dependent effect of early antiplatelet therapy in acute ischaemic stroke. Thromb Haemost 2017; 107:69-79. [DOI: 10.1160/th11-06-0436] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Accepted: 10/14/2011] [Indexed: 01/08/2023]
Abstract
SummaryAntiplatelet agents are essential in treating patients with acute ischaemic stroke (AIS) to prevent recurrent ischaemic events. The aim of this study was to evaluate the effectiveness of early antiplatelet therapy with different aspirin (ASA) dosages in patients with AIS. This observational study included 454 patients with AIS in whom antiplatelet treatment was initiated. The antiplatelet effect was determined by whole blood aggregometry within 48 hours after antplatelet therapy was initiated. An impedance change exceeding 0 Ω after stimulation with arachidonic acid was defined as ASA low response (ALR) and ≥5 Ω in ADP-stimulated specimen as clopidogrel LR. Of the study group 53.5% patients were treated with 200 mg ASA orally, 27.5% with 500 mg ASA intravenously, 8.6% with 100 mg ASA orally, and 7.7% with 75 mg clopidogrel. A dose-dependent antiplatelet effect of ASA treatment was found: 18.4% of patients with 500 mg ASA intravenously were ALR, in contrast to 32.5% on 200 mg and 35.9% on 100 mg ASA orally. Clopidogrel treatment without a loading dose resulted in a high proportion of LR (45.7%). Using the propensity score method revealed a three times higher risk for ALR for patients treated with ASA 200 mg [odds ratio 2.99 (1.55–5.79)] compared to treatment with ASA 500 mg. In conclusion, initiating antiplatelet therapy in patients with AIS resulted in a dose-dependent insufficient platelet inhibitory effect. Our findings suggest using a loading dose of 500 mg ASA intravenously as this seems to be favourable when a sufficient early platelet inhibitory effect is wanted.ClinicalTrials.gov Identifier: NCT01273935
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Rosafio F, Lelli N, Mimmi S, Vandelli L, Bigliardi G, Dell'Acqua ML, Picchetto L, Pentore R, Ferraro D, Trenti T, Nichelli P, Zini A. Platelet Function Testing in Patients with Acute Ischemic Stroke: An Observational Study. J Stroke Cerebrovasc Dis 2017; 26:1864-1873. [PMID: 28576652 DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/21/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The measurement of platelet reactivity in patients with stroke undergoing antiplatelet therapies is not commonly performed in clinical practice. We assessed the prevalence of therapy responsiveness in patients with stroke and further investigated differences between patients on prevention therapy at stroke onset and patients naive to antiplatelet medications. We also sought differences in responsiveness between etiological subtypes and correlations between Clopidogrel responsiveness and genetic polymorphisms. METHODS A total of 624 stroke patients on antiplatelet therapy were included. Two different groups were identified: "non-naive patients", and "naive patients". Platelet function was measured with multiple electrode aggregometry, and genotyping assays were used to determine CYP2C19 polymorphisms. RESULTS Aspirin (ASA) responsiveness was significantly more frequent in naive patients compared with non-naive patients (94.9% versus 82.6%, P < .0010). A better responsiveness to ASA compared with Clopidogrel or combination therapy was found in the entire population (P < .0010), in non-naive patients (P < .0253), and in naive patients (P < .0010). Multivariate analysis revealed a strong effect of Clopidogrel as a possible "risk factor" for unresponsiveness (odds ratio 3.652, P < .0001). No difference between etiological subgroups and no correlations between responsiveness and CYP2C19 polymorphisms were found. CONCLUSION In our opinion, platelet function testing could be potentially useful in monitoring the biological effect of antiplatelet agents. A substantial proportion of patients with stroke on ASA were "resistant", and the treatment with Clopidogrel was accompanied by even higher rates of unresponsiveness. Longitudinal studies are needed to assess whether aggregometry might supply individualized prognostic information and whether it can be considered a valid tool for future prevention strategies.
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Affiliation(s)
- Francesca Rosafio
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | - Nicoletta Lelli
- Clinical Pathology-Toxicology, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | | | - Laura Vandelli
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | - Guido Bigliardi
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | - Maria Luisa Dell'Acqua
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | - Livio Picchetto
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | - Roberta Pentore
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | - Diana Ferraro
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | - Tommaso Trenti
- Clinical Pathology-Toxicology, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | - Paolo Nichelli
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy
| | - Andrea Zini
- Stroke Unit, Neurology Clinic, Department of Neuroscience, Nuovo Ospedale Civile S. Agostino-Estense, University Hospital of Modena, Modena, Italy.
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Aspirin resistance in cerebrovascular disease and the role of glycoprotein IIIa polymorphism in Turkish stroke patients. Blood Coagul Fibrinolysis 2016; 27:169-75. [DOI: 10.1097/mbc.0000000000000404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kim JT, Heo SH, Choi KH, Nam TS, Choi SM, Lee SH, Park MS, Kim BC, Kim MK, Saver JL, Cho KH. Clinical Implications of Changes in Individual Platelet Reactivity to Aspirin Over Time in Acute Ischemic Stroke. Stroke 2015. [PMID: 26219647 DOI: 10.1161/strokeaha.115.009428] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Time-dependent changes in individual platelet reactivity have been detected in patients with coronary artery disease. Therefore, we sought to evaluate the time-dependent changes in platelet reactivity to aspirin during the acute stage after ischemic stroke and the clinical implications of variable patient responses to aspirin in acute ischemic stroke. METHODS We conducted a single-center, prospective, observational study. The acute aspirin reaction unit (ARU) was measured after 3 hours of aspirin loading, with higher values indicating increased platelet reactivity despite aspirin therapy. The follow-up ARU was measured on the fifth day of consecutive aspirin intake. The numeric difference between the follow-up ARU and the acute ARU was defined as ΔARU and was stratified into quartiles. Early neurological deterioration was regarded as an early clinical outcome. RESULTS Both the acute ARU (476±69 IU) and the follow-up ARU (451±68 IU) were measured in 349 patients in this study. Early neurological deterioration was observed in 72 patients (20.6%). Changes in aspirin platelet reactivity over time showed an approximately Gaussian distribution. The highest ΔARU quartile was independently associated with early neurological deterioration (odds ratio, 3.19; 95% confidence interval, 1.43-7.10; P=0.005) by multivariate logistic regression analysis. CONCLUSIONS The results of our study showed that the increase in platelet reactivity to aspirin over time is independently associated with early neurological deterioration in patients with acute ischemic stroke. In addition, during the acute stage of ischemic stroke, serial platelet reactivity assays may be more useful than a single assay for identifying the clinical implications of aspirin platelet reactivity after ischemic stroke.
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Affiliation(s)
- Joon-Tae Kim
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.).
| | - Suk-Hee Heo
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Kang-Ho Choi
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Tai-Seung Nam
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Seong-Min Choi
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Seung-Han Lee
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Man-Seok Park
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Byeong C Kim
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Myeong-Kyu Kim
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Jeffrey L Saver
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Ki-Hyun Cho
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K., K.-H.C., T.-S.N., S.-M.C., S.-H.L., M.-S.P., B.C.K., M.-K.K., K.-H.C.); Department of Radiology, Chonnam National University Hwasun Hospital, Hwasun, Korea (S.-H.H.); and Stroke Center and Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
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Achterberg S, Kappelle LJ, de Bakker PIW, Traylor M, Algra A. No Additional Prognostic Value of Genetic Information in the Prediction of Vascular Events after Cerebral Ischemia of Arterial Origin: The PROMISe Study. PLoS One 2015; 10:e0119203. [PMID: 25906364 PMCID: PMC4408031 DOI: 10.1371/journal.pone.0119203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 01/11/2015] [Indexed: 11/18/2022] Open
Abstract
Background Patients who have suffered from cerebral ischemia have a high risk of recurrent vascular events. Predictive models based on classical risk factors typically have limited prognostic value. Given that cerebral ischemia has a heritable component, genetic information might improve performance of these risk models. Our aim was to develop and compare two models: one containing traditional vascular risk factors, the other also including genetic information. Methods and Results We studied 1020 patients with cerebral ischemia and genotyped them with the Illumina Immunochip. Median follow-up time was 6.5 years; the annual incidence of new ischemic events (primary outcome, n=198) was 3.0%. The prognostic model based on classical vascular risk factors had an area under the receiver operating characteristics curve (AUC-ROC) of 0.65 (95% confidence interval 0.61-0.69). When we added a genetic risk score based on prioritized SNPs from a genome-wide association study of ischemic stroke (using summary statistics from the METASTROKE study which included 12389 cases and 62004 controls), the AUC-ROC remained the same. Similar results were found for the secondary outcome ischemic stroke. Conclusions We found no additional value of genetic information in a prognostic model for the risk of ischemic events in patients with cerebral ischemia of arterial origin. This is consistent with a complex, polygenic architecture, where many genes of weak effect likely act in concert to influence the heritable risk of an individual to develop (recurrent) vascular events. At present, genetic information cannot help clinicians to distinguish patients at high risk for recurrent vascular events.
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Affiliation(s)
- Sefanja Achterberg
- Department of Neurology and Neurosurgery, Utrecht Stroke Center, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- * E-mail:
| | - L. Jaap Kappelle
- Department of Neurology and Neurosurgery, Utrecht Stroke Center, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Paul I. W. de Bakker
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Medical Genetics, Center for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthew Traylor
- Clinical Neurosciences, University of Cambridge, Cambridge, CB2 0QQ, United Kingdom
| | - Ale Algra
- Department of Neurology and Neurosurgery, Utrecht Stroke Center, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Lago A, Parkhutik V, Tembl JI, Vallés J, Santos MT, Moscardó A. Assessment of Platelet Function in Acute Ischemic Stroke Patients Previously Treated with Aspirin. J Stroke Cerebrovasc Dis 2014; 23:2794-2799. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 05/29/2014] [Accepted: 07/02/2014] [Indexed: 11/25/2022] Open
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Chinese herbal medicine for aspirin resistance: a systematic review of randomized controlled trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2014; 2014:890950. [PMID: 24701247 PMCID: PMC3950618 DOI: 10.1155/2014/890950] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/15/2013] [Accepted: 12/16/2013] [Indexed: 11/18/2022]
Abstract
Aspirin resistance (AR) is a prevalent phenomenon and leads to significant clinical consequences, but the current evidence for effective interventional strategy is insufficient. The objective of this systematic review is thus to assess the efficacy and safety of Chinese herbal medicine (CHM) for AR. A systematical literature search was conducted in 6 databases until December 2012 to identify randomized controlled trials (RCTs) of CHM for AR. As a result, sixteen RCTs with a total of 1011 subjects were identified, suggesting that the interests of the medical profession and the public in the use of CHM for AR have grown considerably in the recent years. Tongxinluo capsule and Danshen-based prescriptions were the most frequently used herbal prescriptions, while danshen root, milkvetch root, Leech, and Rosewood were the most frequently used single herbs. Despite the apparent reported positive findings, it is premature to determine the efficacy and safety of CHM for the treatment of AR due to poor methodological quality and insufficient safety data. However, CHMs appeared to be well tolerated in all included studies. Thus, CHM as a promising candidate is worthy of improvement and development for further clinical AR trials. Large sample-size and well-designed rigorous RCTs are needed.
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Castilla-Guerra L, Navas-Alcántara M, Fernández-Moreno M. Aspirin resistant patients with recent ischemic stroke. Rev Clin Esp 2014. [DOI: 10.1016/j.rceng.2013.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Aspirin resistant patients with recent ischemic stroke. Rev Clin Esp 2013; 214:145-9. [PMID: 24211052 DOI: 10.1016/j.rce.2013.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 09/24/2013] [Accepted: 10/02/2013] [Indexed: 11/20/2022]
Abstract
Some patients with a recent ischemic stroke who are being treated with aspirin as an antiaggregant suffer a new ischemic stroke. These patients (15-25%) have been called unresponsive to aspirin or aspirin resistant. The aspirin-resistant patients have a four-time greater risk of suffering a stroke. Furthermore, these strokes are generally more severe, with increased infarct volume and greater risk of recurrence. There is currently no ideal laboratory test to detect the resistance to the antiaggregant effect of aspirin. The study of resistance to aspirin would only be indicated in selected cases. In these patients, one should first rule out any "pseudo-resistance" to aspirin (lack of compliance, concomitant treatments that interfere with the action of the aspirin).
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Gorelick PB, Farooq MU. Advances in our understanding of "resistance" to antiplatelet agents for prevention of ischemic stroke. Stroke Res Treat 2013; 2013:727842. [PMID: 23936730 PMCID: PMC3725785 DOI: 10.1155/2013/727842] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 05/27/2013] [Indexed: 01/10/2023] Open
Abstract
We review the role of aspirin and clopidogrel for prevention of ischemic stroke and explore the concept of antiplatelet therapy resistance both from a laboratory and clinical perspective and genetic polymorphisms that might influence platelet reactivity with clopidogrel administration. Debates have raged over the years about the application of platelet function tests in clinical practice. We conclude that platelet function testing is not indicated in routine clinical practice. This recommendation is supported by clinical guideline statements, a lack of a global platelet function measure, and limitations of current platelet function test methods as applied in practice. We discuss a recently hypothesized hierarchy of patient characteristics in relation to which patients are most likely to benefit from platelet function studies based on acuity (i.e., risk) of cardiovascular disease. A focus of antiplatelet therapy administration should include emphasis on compliance/adherence and in the example of aspirin, use of well-absorbed forms of aspirin and avoidance of drugs that may interact with aspirin to inhibit its mechanism of action (e.g., certain nonsteroidal anti-inflammatory drugs).
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Affiliation(s)
- Philip B. Gorelick
- Hauenstein Neuroscience Center, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
- Department of Translational Science and Molecular Medicine, Michigan State University College of Human Medicine, 333 Bostwick Avenue NE, Grand Rapids, MI 49503, USA
| | - Muhammad U. Farooq
- Hauenstein Neuroscience Center, 220 Cherry Street SE, Grand Rapids, MI 49503, USA
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Abstract
Antiplatelet treatment is a mainstay in acute and long-term secondary stroke prevention. Aspirin is still most widely used worldwide, however, there is increasing evidence from small randomised trials that dual antiplatelet therapy combining aspirin with dipyridamole or clopidogrel might be more effective in the acute and early chronic post-ischemic phase (i.e. first 90 days). Both clopidogrel and the combination of aspirin and extended-release dipyridamole are recommended by current guidelines in long-term secondary stroke prevention in patients who are at high risk for a recurrent ischemic stroke, since they are more effective compared with aspirin monotherapy. Antiplatelet agents are the therapy of choice in patients with ischemic stroke due to intracranial stenosis and patent foramen ovale. In contrast, oral anticoagulation is clearly superior to single or double antiplatelet therapy in patients with cardioembolic stroke, mainly caused by atrial fibrillation.Concerning newer antiplatelet agents, only cilostazol appears to be a promising therapeutic option in patients with ischemic stroke in the near future, but so far, only studies in Asian stroke patients have been performed.
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Affiliation(s)
- Ralph Weber
- Department of Neurology and Stroke Center, University Duisburg-Essen, Hufelandstr. 55, 45122, Essen, Germany
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Oxley TJ, Dowling RJ, Mitchell PJ, Davis S, Yan B. Antiplatelet resistance and thromboembolic complications in neurointerventional procedures. Front Neurol 2011; 2:83. [PMID: 22363312 PMCID: PMC3277275 DOI: 10.3389/fneur.2011.00083] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 11/30/2011] [Indexed: 12/04/2022] Open
Abstract
Antiplatelet resistance is emerging as a significant factor in effective secondary stroke prevention. Prevalence of aspirin and clopidogrel resistance is dependent upon laboratory test and remains contentious. Large studies in cardiovascular disease populations have demonstrated worse ischemic outcomes in patients with antiplatelet resistance, particularly in patients with coronary stents. Thromboembolism is a complication of neurointerventional procedures that leads to stroke. Stroke rates related to aneurysm coiling range from 2 to 10% and may be higher when considering silent ischemia. Stroke associated with carotid stenting is a major cause of morbidity. Antiplatelet use in the periprocedure setting varies among different centers. No guidelines exist for use of antiplatelet regimens in neurointerventional procedures. Incidence of stroke in patients post procedure may be partly explained by resistance to antiplatelet agents. Further research is required to establish the incidence of stroke in patients with antiplatelet resistance undergoing neurointerventional procedures.
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Affiliation(s)
- Thomas J. Oxley
- Department of Neurology, The Royal Melbourne HospitalMelbourne, VIC, Australia
| | - Richard J. Dowling
- Department of Radiology, The Royal Melbourne HospitalMelbourne, VIC, Australia
| | - Peter J. Mitchell
- Department of Radiology, The Royal Melbourne HospitalMelbourne, VIC, Australia
| | - Stephen Davis
- Department of Neurology, The Royal Melbourne HospitalMelbourne, VIC, Australia
| | - Bernard Yan
- Department of Neurology, The Royal Melbourne HospitalMelbourne, VIC, Australia
- Department of Radiology, The Royal Melbourne HospitalMelbourne, VIC, Australia
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Attività piastrinica residua e fallimento clinico della profilassi antitrombotica nell’attacco ischemico cerebrale acuto. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s13631-011-0024-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lutsep H. Update on selecting and adjusting antiplatelet therapy for prevention of noncardiogenic, recurrent ischemic stroke. Expert Rev Cardiovasc Ther 2011; 9:1295-303. [DOI: 10.1586/erc.11.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Feher A, Pusch G, Harang G, Gasztonyi B, Papp E, Werling D, Menyhart M, Komaromy H, Szapary L, Feher G. Aspirin resistance in cerebrovascular patients. Int J Cardiol 2011; 152:111-2. [PMID: 21794938 DOI: 10.1016/j.ijcard.2011.07.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 07/06/2011] [Indexed: 01/10/2023]
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Abstract
Although the exact prevalence of antiplatelet resistance in ischemic stroke is not known, estimates about the two most widely used antiplatelet agents - aspirin and clopidogrel - suggest that the resistance rate is high, irrespective of the definition used and parameters measured. Inadequate antiplatelet responsiveness correlates with an increased risk of recurrent ischemic vascular events in patients with stroke and acute coronary syndrome. It is not currently known whether tailoring antiplatelet therapy based on platelet function test results translates into a more effective strategy to prevent secondary vascular events after stroke. Large-scale clinical trials using a universally accepted definition and standardized measurement techniques for antiplatelet resistance are needed to demonstrate whether a 'platelet-function test-guided antiplatelet treatment' strategy translates into improved stroke care. This article gives an overview of the clinical importance of laboratory antiplatelet resistance, describes the challenges for platelet-function test-guided antiplatelet treatment and discusses practical issues about the management of patients with aspirin and/or clopidogrel resistance.
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Affiliation(s)
| | | | - Hakan Ay
- Stroke Service, Department of Neurology, AA Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, CNY-149-2301, Boston, MA 02129, USA
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