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Qu HL, Sun XY, He C, Chen HS. Sex Differences in the Dual Antiplatelet Therapy Versus Alteplase for Patients with Minor Nondisabling Acute Ischemic Stroke: A Secondary Analysis of the ARAMIS Study. CNS Drugs 2024; 38:649-659. [PMID: 38806883 DOI: 10.1007/s40263-024-01096-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND AND PURPOSE Sex is associated with clinical outcome in stroke. The present study aimed to determine the effect of sex on efficacy of dual antiplatelet (DAPT) versus alteplase in ischemic stroke based on Antiplatelet versus recombinant tissue plasminogen activator (R-tPA) for Acute Mild Ischemic Stroke (ARAMIS) trial. METHODS In this secondary analysis of the ARAMIS study, eligible patients aged 18 years or older with minor nondisabling stroke who received dual antiplatelet therapy or intravenous alteplase within 4.5 h of stroke onset were divided into two groups: men and women. The primary endpoint was an excellent functional outcome, defined as a modified Rankin Scale (mRS) 0-1 at 90 days. Binary logistic regression analyses and generalized linear models were used. RESULTS Of the 719 patients who completed the study, 31% (223) were women, and 69% (496) were men. There were no significant sex differences in excellent functional outcome (unadjusted p = 0.304 for men and p = 0.993 for women; adjusted p = 0.376 for men and p = 0.918 for women) and favorable functional outcome (mRS score of 0-2; unadjusted p = 0.968 for men and p = 0.881 for women; adjusted p = 0.824 for men and p = 0.881 for women). But for the secondary outcomes, compared with alteplase, DAPT was associated with a significantly decreased proportion of early neurological deterioration within 24 h in men {unadjusted odds ratio [OR] = 0.440 [95% confidence interval (CI), 0.221-0.878]; p = 0.020; adjusted OR = 0.436 [95% CI, 0.216-0.877]; p = 0.020}, but not in women [unadjusted OR = 0.636 (95% CI, 0.175-2.319), p = 0.490; adjusted OR = 0.687 (95% CI, 0.181-2.609), p = 0.581]. For the safety outcomes, compared with the DAPT group, alteplase was associated with a significantly increased proportion of any bleeding events in men [unadjusted OR = 3.110 (95% CI, 1.103-8.770); p = 0.032], but not in women [unadjusted OR = 5.333 (95% CI, 0.613-46.407), p = 0.129; adjusted OR = 5.394 (95% CI, 0.592-49.112), p = 0.135]. CONCLUSION Sex did not influence the effect of dual antiplatelet therapy versus intravenous alteplase in minor nondisabling stroke, but more early neurological deterioration and bleeding events occurred in men who received alteplase.
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Affiliation(s)
- Hui-Ling Qu
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Xiao-Yu Sun
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Chao He
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China
| | - Hui-Sheng Chen
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, 110016, China.
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Krychtiuk KA, Gersh BJ, Washam JB, Granger CB. When cardiovascular medicines should be discontinued. Eur Heart J 2024; 45:2039-2051. [PMID: 38838241 DOI: 10.1093/eurheartj/ehae302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/19/2024] [Accepted: 05/05/2024] [Indexed: 06/07/2024] Open
Abstract
An integral component of the practice of medicine is focused on the initiation of medications, based on clinical practice guidelines and underlying trial evidence, which usually test the addition of novel medications intended for life-long use in short-term clinical trials. Much less attention is given to the question of medication discontinuation, especially after a lengthy period of treatment, during which patients age gets older and diseases may either progress or new diseases may emerge. Given the paucity of data, clinical practice guidelines offer little to no guidance on when and how to deprescribe cardiovascular medications. Such decisions are often left to the discretion of clinicians, who, together with their patients, express concern of potential adverse effects of medication discontinuation. Even in the absence of adverse effects, the continuation of medications without any proven effect may cause harm due to drug-drug interactions, the emergence of polypharmacy, and additional preventable spending to already strained health systems. Herein, several cardiovascular medications or medication classes are discussed that in the opinion of this author group should generally be discontinued, either for the prevention of potential harm, for a lack of benefit, or for the availability of better alternatives.
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Affiliation(s)
- Konstantin A Krychtiuk
- Duke Clinical Research Institute, 300 W Morgan Street, Durham, NC 27701, USA
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jeffrey B Washam
- Division of Clinical Pharmacology, Department of Medicine, Duke University, Durham, NC, USA
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De Matteis E, Ornello R, De Santis F, Foschi M, Romoli M, Tassinari T, Saia V, Cenciarelli S, Bedetti C, Padiglioni C, Censori B, Puglisi V, Vinciguerra L, Guarino M, Barone V, Zedde M, Grisendi I, Diomedi M, Bagnato MR, Petruzzellis M, Mezzapesa DM, Di Viesti P, Inchingolo V, Cappellari M, Zenorini M, Candelaresi P, Andreone V, Rinaldi G, Bavaro A, Cavallini A, Moraru S, Querzani P, Terruso V, Mannino M, Pezzini A, Frisullo G, Muscia F, Paciaroni M, Mosconi MG, Zini A, Leone R, Palmieri C, Cupini LM, Marcon M, Tassi R, Sanzaro E, Paci C, Viticchi G, Orsucci D, Falcou A, Diamanti S, Tarletti R, Nencini P, Rota E, Sepe FN, Ferrandi D, Caputi L, Volpi G, Spada SL, Beccia M, Rinaldi C, Mastrangelo V, Di Blasio F, Invernizzi P, Pelliccioni G, De Angelis MV, Bonanni L, Ruzza G, Caggia EA, Russo M, Tonon A, Acciarri MC, Anticoli S, Roberti C, Manobianca G, Scaglione G, Pistoia F, Fortini A, De Boni A, Sanna A, Chiti A, Barbarini L, Caggiula M, Masato M, Del Sette M, Passarelli F, Roberta Bongioanni M, Toni D, Ricci S, Sacco S. Beyond RCTs: Short-term dual antiplatelet therapy in secondary prevention of ischemic stroke and transient ischemic attack. Eur Stroke J 2024:23969873241255250. [PMID: 38869034 DOI: 10.1177/23969873241255250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND AND PURPOSE Randomized controlled trials (RCTs) proved the efficacy of short-term dual antiplatelet therapy (DAPT) in secondary prevention of minor ischemic stroke or high-risk transient ischemic attack (TIA). We aimed at evaluating effectiveness and safety of short-term DAPT in real-world, where treatment use is broader than in RCTs. METHODS READAPT (REAl-life study on short-term Dual Antiplatelet treatment in Patients with ischemic stroke or Transient ischemic attack) (NCT05476081) was an observational multicenter real-world study with a 90-day follow-up. We included patients aged 18+ receiving short-term DAPT soon after ischemic stroke or TIA. No stringent NIHSS and ABCD2 score cut-offs were applied but adherence to guidelines was recommended. Primary effectiveness outcome was stroke (ischemic or hemorrhagic) or death due to vascular causes, primary safety outcome was moderate-to-severe bleeding. Secondary outcomes were the type of ischemic and hemorrhagic events, disability, cause of death, and compliance to treatment. RESULTS We included 1920 patients; 69.9% started DAPT after an ischemic stroke; only 8.9% strictly followed entry criteria or procedures of RCTs. Primary effectiveness outcome occurred in 3.9% and primary safety outcome in 0.6% of cases. In total, 3.3% cerebrovascular ischemic recurrences occurred, 0.2% intracerebral hemorrhages, and 2.7% bleedings; 0.2% of patients died due to vascular causes. Patients with NIHSS score ⩽5 and those without acute lesions at neuroimaging had significantly higher primary effectiveness outcomes than their counterparts. Additionally, DAPT start >24 h after symptom onset was associated with a lower likelihood of bleeding. CONCLUSIONS In real-world, most of the patients who receive DAPT after an ischemic stroke or a TIA do not follow RCTs entry criteria and procedures. Nevertheless, short-term DAPT remains effective and safe in this population. No safety concerns are raised in patients with low-risk TIA, more severe stroke, and delayed treatment start.
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Affiliation(s)
- Eleonora De Matteis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
- Department of Brain Sciences, Imperial College London, London, UK
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Federico De Santis
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Michele Romoli
- Department of Neuroscience, Maurizio Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Tiziana Tassinari
- Department of Neurology, Santa Corona Hospital, Pietra Ligure, Italy
| | - Valentina Saia
- Department of Neurology, Santa Corona Hospital, Pietra Ligure, Italy
| | - Silvia Cenciarelli
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
| | - Chiara Bedetti
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
| | - Chiara Padiglioni
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
| | - Bruno Censori
- Department of Neurology, ASST Cremona Hospital, Cremona, Italy
| | | | | | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Valentina Barone
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Ilaria Grisendi
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marina Diomedi
- Department of Systems Medicine, Tor Vergata University Hospital, Rome, Italy
| | | | - Marco Petruzzellis
- Department of Neurology and Stroke Unit, "F. Puca" AOU Consorziale Policlinico, Bari, Italy
| | | | - Pietro Di Viesti
- Department of Neurology, Fondazione IRCCS Casa sollievo della sofferenza, San Giovanni Rotondo, Italy
| | - Vincenzo Inchingolo
- Department of Neurology, Fondazione IRCCS Casa sollievo della sofferenza, San Giovanni Rotondo, Italy
| | - Manuel Cappellari
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona
| | - Mara Zenorini
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata Verona, Verona
| | - Paolo Candelaresi
- Department of Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - Vincenzo Andreone
- Department of Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | | | | | - Anna Cavallini
- UO Neurologia d'Urgenza e Stroke Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Stefan Moraru
- UO Neurologia d'Urgenza e Stroke Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Pietro Querzani
- Department of Neuroscience, S.Maria delle Croci Hospital, AUSL Romagna, Ravenna, Italy
| | - Valeria Terruso
- Department of Neurology, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Marina Mannino
- Department of Neurology, AOOR Villa Sofia-Cervello, Palermo, Italy
| | - Alessandro Pezzini
- Department of Medicine and Surgery, University of Parma, Stroke Care Program, Department of Emergency, Parma University Hospital, Parma, Italy
| | - Giovanni Frisullo
- Neuroscienze, Organi di Senso e Torace, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | | | - Maurizio Paciaroni
- Department of Internal and Cardiovascular Medicine - Stroke Unit, University Hospital Santa Maria della Misericordia, Perugia, Italy
| | - Maria Giulia Mosconi
- Department of Internal and Cardiovascular Medicine - Stroke Unit, University Hospital Santa Maria della Misericordia, Perugia, Italy
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Ruggiero Leone
- Department of Neurology and Stroke Unit, "M. R. Dimiccoli" General Hospital, Barletta, ASL BT, Italy
| | - Carmela Palmieri
- Medical Department, E. Agnelli Hospital - Local Health Company (ASL) TO3, Pinerolo, Italy
| | | | - Michela Marcon
- Department of Neurology, Cazzavillan Hospital Arzignano, Vicenza, Italy
| | - Rossana Tassi
- Stroke Unit, Urgency and Emergency Department, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Enzo Sanzaro
- Department of Neurology, Umberto I Hospital, Siracusa, Italy
| | - Cristina Paci
- UOC Neurologia, Ospedale "Madonna del Soccorso", San Benedetto del Tronto, Italy
| | - Giovanna Viticchi
- Experimental and Clinical Medicine Department, Marche Polytechnic University, Ancona
| | - Daniele Orsucci
- Unit of Neurology-San Luca Hospital, Lucca and Castelnuovo Garfagnana, Italy
| | - Anne Falcou
- Stroke Unit, Emergency Department, Policlinico Umberto I Hospital, Rome, Italy
| | - Susanna Diamanti
- Department of Neurology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Roberto Tarletti
- SCDU Neurologia - Stroke Unit, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
| | | | - Eugenia Rota
- Department of Neurology, San Giacomo Hospital, Novi Ligure, Italy
| | | | - Delfina Ferrandi
- Stroke Unit-Department of Neurology, SS. Biagio e Arrigo Hospital, Alessandria, Italy
| | - Luigi Caputi
- Department of Cardiocerebrovascular diseases, Neurology-Stroke Unit-ASST Ospedale Maggiore di Crema, Crema, Italy
| | - Gino Volpi
- Department of Neurology, San Jacopo Hospital, Pistoia, Italy
| | | | - Mario Beccia
- Department of Neurology, Sant'Andrea Hospital, Rome, Italy
| | - Claudia Rinaldi
- Neurology Unit, "Infermi" Hospital, AUSL Romagna, Rimini, Italy
| | | | | | - Paolo Invernizzi
- Departiment of Neurology, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | | | - Maria Vittoria De Angelis
- Stroke Unit, "S.Spirito" Hospital, Pescara, Italy
- Department of Neurology and Stroke Unit, SS Annunziata Hospital, Chieti, Italy
| | - Laura Bonanni
- Dipartimento di Medicina e Scienze dell'Invecchiamento, Università G. d'Annunzio di Chieti-Pescara e Clinica Neurologica e Stroke Unit Ospedale Clinicizzato SS. Annunziata di Chieti, Chieti, Italy
| | | | | | - Monia Russo
- Department of Neurology, St Misericordia Hospital, Rovigo, Italy
| | - Agnese Tonon
- Department of Neurology, Ospedale Civile Ss. Giovanni e Paolo, Venice, Italy
| | | | | | - Cinzia Roberti
- Department of Neurology, San Filippo Neri Hospital, Rome, Italy
| | - Giovanni Manobianca
- Department of Neurology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Gaspare Scaglione
- Department of Neurology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Alberto Fortini
- Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy
| | | | | | - Alberto Chiti
- Unit of Neurology, Apuane Hospital, Massa Carrara, Italy
| | | | | | - Maela Masato
- Department of Neurology, Mirano Hospital, Mirano, Italy
| | - Massimo Del Sette
- Department of Neuroscience, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | - Danilo Toni
- Department of Human neurosciences, University of Rome La Sapienza, Rome, Italy
| | - Stefano Ricci
- Department of Neurology, Città di Castello Hospital, Città di Castello, Italy
- Coordinatore Comitato Scientifico ISA-AII
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Qin B, Fu L, Qin H, Liang Y, Qin C, Zhang J, Gao W. Intravenous thrombolysis versus dual antiplatelet therapy for patients with acute minor ischaemic stroke: a systematic review and meta-analysis. Front Pharmacol 2024; 15:1377475. [PMID: 38915465 PMCID: PMC11194400 DOI: 10.3389/fphar.2024.1377475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/24/2024] [Indexed: 06/26/2024] Open
Abstract
Background and purpose The efficacy of intravenous thrombolysis (IVT) in patients with acute minor ischaemic stroke (AMIS) remains unclear. We performed a meta-analysis to compare the efficacy and safety of IVT and dual antiplatelet therapy (DAPT) in patients with AMIS. Methods The Embase, Cochrane Library, PubMed, and Web of Science databases were searched up to 10 October, 2023. Prospective and retrospective studies comparing the clinical outcomes of IVT and DAPT were included. Odds ratios (ORs) and 95% confidence intervals (CIs) for early neurological deterioration (END), excellent and favourable functional outcomes, recurrent ischaemic stroke at 3 months, mortality at 3 months, and symptomatic intracranial haemorrhage (ICH) were pooled using a random-effects model. Results Of the five included studies, 6,340 patients were included. In patients with AMIS, IVT was not significantly associated with excellent and favourable functional outcomes, recurrent ischaemic stroke, or all-cause mortality at 3 months compared to early DAPT. However, a higher risk of symptomatic ICH (OR, 9.31; 95% CI, 3.39-25.57) and END (OR, 2.75; 95% CI, 1.76-4.30) were observed with IVT. Conclusion This meta-analysis indicated that IVT was not superior to DAPT in patients with AMIS, especially in those with nondisabling AIS. However, these findings should be interpreted with caution and have some limitations. Further, well-designed randomised controlled trials are warranted.
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Affiliation(s)
- Bin Qin
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lin Fu
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Huixun Qin
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Yuming Liang
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Cheng Qin
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Jiede Zhang
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Wen Gao
- Department of Neurology, Liuzhou People’s Hospital, Liuzhou, Guangxi, China
- Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
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Chen HS, Cui Y, Wang XH, Ma YT, Han J, Duan YJ, Lu J, Shen LY, Liang Y, Wang WZ, Wang H, Zhao Y, Zhang JT, Song YL, He XM, Li RH, Tao DB, Li J, Huang SM, Wang N, Hong M, Meng C, Zhang W, Wang DL, Nguyen TN. Clopidogrel Plus Aspirin vs Aspirin Alone in Patients With Acute Mild to Moderate Stroke: The ATAMIS Randomized Clinical Trial. JAMA Neurol 2024; 81:450-460. [PMID: 38466274 PMCID: PMC10928538 DOI: 10.1001/jamaneurol.2024.0146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/11/2024] [Indexed: 03/12/2024]
Abstract
Importance Dual antiplatelet therapy has been demonstrated to be superior to single antiplatelet in reducing recurrent stroke among patients with transient ischemic attack or minor stroke, but robust evidence for its effect in patients with mild to moderate ischemic stroke is lacking. Objective To evaluate whether dual antiplatelet therapy is superior to single antiplatelet among patients with mild to moderate ischemic stroke. Design, Setting, and Participants This was a multicenter, open-label, blinded end point, randomized clinical trial conducted at 66 hospitals in China from December 20, 2016, through August 9, 2022. The date of final follow-up was October 30, 2022. The analysis was reported on March 12, 2023. Of 3065 patients with ischemic stroke, 3000 patients with acute mild to moderate stroke within 48 hours of symptom onset were enrolled, after excluding 65 patients who did not meet eligibility criteria or had no randomization outcome. Interventions Within 48 hours after symptom onset, patients were randomly assigned to receive clopidogrel plus aspirin (n = 1541) or aspirin alone (n = 1459) in a 1:1 ratio. Main Outcomes and Measures The primary end point was early neurologic deterioration at 7 days, defined as an increase of 2 or more points in National Institutes of Health Stroke Scale (NIHSS) score, but not as a result of cerebral hemorrhage, compared with baseline. The superiority of clopidogrel plus aspirin to aspirin alone was assessed based on a modified intention-to-treat population, which included all randomized participants with at least 1 efficacy evaluation regardless of treatment allocation. Bleeding events were safety end points. Results Of the 3000 randomized patients, 1942 (64.6%) were men, the mean (SD) age was 65.9 (10.6) years, median (IQR) NIHSS score at admission was 5 (4-6), and 1830 (61.0%) had a stroke of undetermined cause. A total of 2915 patients were included in the modified intention-to-treat analysis. Early neurologic deterioration occurred in 72 of 1502 (4.8%) in the dual antiplatelet therapy group vs 95 of 1413 (6.7%) in the aspirin alone group (risk difference -1.9%; 95% CI, -3.6 to -0.2; P = .03). Similar bleeding events were found between 2 groups. Conclusions and Relevance Among Chinese patients with acute mild to moderate ischemic stroke, clopidogrel plus aspirin was superior to aspirin alone with regard to reducing early neurologic deterioration at 7 days with similar safety profile. These findings indicate that dual antiplatelet therapy may be a superior choice to aspirin alone in treating patients with acute mild to moderate stroke. Trial Registration ClinicalTrials.gov Identifier: NCT02869009.
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Affiliation(s)
- Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Xin-Hong Wang
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yu-Tong Ma
- Department of Neurology, Beipiao Central Hospital, Beipiao, China
| | - Jing Han
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Ying-Jie Duan
- Department of Neurology, General Hospital of Fuxin Mining Industry Group of Liaoning Health Industry Group, Fuxin, China
| | - Jiang Lu
- Department of Neurology, Linghai Dalinghe Hospital, Jinzhou, China
| | - Li-Ying Shen
- Department of Neurology, Tieling County Central Hospital, Tieling, China
| | - Yong Liang
- Department of Neurology, Tieling Central Hospital, Tieling, China
| | - Wei-Zhong Wang
- Department of Neurology, Dandong Central Hospital, Dandong, China
| | - Hui Wang
- Department of Neurology, Chinese People’s Liberation Army 966 Hospital, Dandong, China
| | - Yong Zhao
- Department of Neurology, Haicheng Traditional Chinese Medicine Hospital, Haicheng, China
| | - Jin-Tao Zhang
- Department of Neurology, Chinese People’s Liberation Army 960 Hospital, Taian, China
| | - Yu-Lin Song
- Department of Neurology, Anshan Changda Hospital, Anshan, China
| | - Xiao-Mei He
- Department of Neurology, Chaoyang Central Hospital, Chaoyang, China
| | - Run-Hui Li
- Department of Neurology, The Affiliated Central Hospital of Shenyang Medical College, Shenyang, China
| | - Ding-Bo Tao
- Department of Neurology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jing Li
- Department of Neurology, Donggang Central Hospital, Donggang, China
| | - Shu-Man Huang
- Department of Neurology, Dawa District People’s Hospital, Panjin, China
| | - Ni Wang
- Department of Neurology, Wafangdian Central Hospital, Wafangdian, China
| | - Mei Hong
- Department of Neurology, China Railway 19th Bureau Group Central Hospital, Liaoyang, China
| | - Chong Meng
- Department of Neurology, Liaoyang County Central Hospital, Liaoyang, China
| | - Wei Zhang
- Department of Neurology, Liaoning Electrical Power Central Hospital, Shenyang, China
| | - Duo-Lao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Thanh N. Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
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Li J, Pan Y, Wang M, Meng X, Lin J, Li Z, Li H, Wang Y, Zhao X, Liu L, Wang Y. High-Sensitivity C-reactive Protein and Intracranial Arterial Stenosis Predicted Recurrent Stroke and Dependence or Death in Minor Stroke or Transient Ischemic Attack. J Atheroscler Thromb 2024; 31:249-258. [PMID: 37704441 PMCID: PMC10918048 DOI: 10.5551/jat.64229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/18/2023] [Indexed: 09/15/2023] Open
Abstract
AIMS Inflammation is associated with vascular events. We aimed to investigate the relationship between high-sensitivity C-reactive protein (hsCRP) levels with and without intracranial arterial stenosis (ICAS) and the prognosis of patients with minor stroke or transient ischemic attack. METHODS We used data from the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events trial (derivation cohort) and the Third China National Stroke Registry (validation cohort). Patients were divided into four groups according to the dichotomy of hsCRP level and ICAS status. The primary outcome was new ischemic stroke within 90 days, and the secondary outcome was dependence or death (Modified Rankin Scale score of 3-6) at 90 days. The associations between hsCRP level with and without ICAS and risk of outcomes were analyzed using multivariate Cox regression and logistic regression models. RESULTS In the derivation cohort, compared with patients with nonelevated hsCRP levels and no ICAS, those with both elevated hsCRP levels and ICAS had increased risk of recurrent stroke (adjusted hazard ratio [HR], 2.62; 95% confidence interval [CI], 1.28-5.34; p=0.008) and dependence or death (adjusted odds ratio [OR], 7.58; 95% CI, 1.30-44.13; p=0.02). Consistent relationships of elevated hsCRP levels and presence of ICAS with recurrent stroke (adjusted HR, 1.67; 95% CI, 1.13-2.45; p=0.009) and dependence or death (adjusted OR, 1.87; 95% CI, 1.23-2.84; p=0.003) were observed in the validation cohort. CONCLUSION Concomitant presence of increased hsCRP levels and ICAS was associated with increased risk of stroke recurrence and dependence or death in patients with minor ischemic stroke or transient ischemic attack.
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Affiliation(s)
- Jiejie Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University and China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases; Advanced Innovation Center for Human Brain Protection, Capital Medical University and Clinical Center for Precision Medicine in Stroke, Capital Medical University, Beijing, China
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7
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Cui Y, Li XQ, Chen HS. Dual antiplatelet instead of intravenous thrombolysis for minor nondisabling acute ischemic stroke: A perspective from China. J Transl Int Med 2024; 12:1-4. [PMID: 38525443 PMCID: PMC10956727 DOI: 10.2478/jtim-2023-0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Affiliation(s)
- Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, Liaoning, Province, China
| | - Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, Liaoning, Province, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, 110016, Liaoning, Province, China
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8
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Kim AS. Extending Dual Antiplatelet Therapy for TIA or Stroke. N Engl J Med 2023; 389:2478-2479. [PMID: 38157504 DOI: 10.1056/nejme2311961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Anthony S Kim
- From the UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco
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9
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Brorson JR, Giurcanu M, Prabhakaran S, Johnston SC. Vulnerable and Stabilized States After Cerebral Ischemic Events: Implications of Kinetic Modeling in the SOCRATES, POINT, and THALES Trials. Neurology 2023; 101:e2205-e2214. [PMID: 37857494 PMCID: PMC10727217 DOI: 10.1212/wnl.0000000000207904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/15/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Trials of acute secondary prevention after minor stroke or transient ischemic attack (TIA), such as SOCRATES, POINT, and THALES, demonstrate a high initial rate of recurrence after ischemic events that drop quickly to a lower rate, suggesting a transient vulnerable clinical state, which may call for different treatments than the subsequent stabilized state. A kinetic model incorporating vulnerable and stabilized states provides estimates of the distinct kinetic rates reflecting the temporal features of underlying stroke mechanisms. We aimed to compare these kinetic rates between treatments and across trials, asking whether these features point to common pathophysiologic processes underlying stroke recurrence, and inform the targeting and timing of enhanced antiplatelet therapy in recurrent stroke prevention. METHODS Kaplan-Meier recurrence-free survival curves in the SOCRATES, POINT, and THALES trials were estimated for each treatment group and fitted by nonlinear regression to the 2-state kinetic model, producing estimates of kinetic parameters, with standard errors estimated using the nonparametric bootstrap with repetitive resampling. RESULTS For each trial, the 2-state kinetic model fit the survival curves better than did the null (single-state) kinetic model or the Weibull model (p < 0.05). Recurrence rates in the vulnerable state (k 1 ) were 100-fold higher than in the stabilized state (k 2 ). Transition rates from the vulnerable to stabilized state (k 0 ) were still more rapid. Kinetic parameters were consistent across the trials, without significant differences between the trials. Enhanced antiplatelet regimens produced significant reductions in k 1 (aspirin alone: 0.030 ± 0.004 d-1; active treatment: 0.016 ± 0.003 d-1; p < 0.01) but did not affect k 0 or k 2 , suggesting that active treatment only affected risk in the vulnerable state. Modeling based on these kinetic parameters suggests that most of the benefit of active treatment occurred within 3 days. DISCUSSION Across multiple trials of acute secondary prevention after minor stroke or TIA, recurrence of stroke is well-described by a 2-state kinetic model postulating vulnerable and stabilized states, with similar kinetic parameters across trials. Enhanced antiplatelet regimens only affected the recurrence rates in the vulnerable state, over a brief period. This analysis suggests that 2 distinct states follow acute cerebral ischemic events, subject to differential impact of immediate or delayed therapies.
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Affiliation(s)
- James R Brorson
- From the Departments of Neurology (J.R.B., S.P.) and Public Health Sciences (M.G.), The University of Chicago, IL; and CMO and cofounder (S.C.J.), Harbor Health, Austin, TX.
| | - Mihai Giurcanu
- From the Departments of Neurology (J.R.B., S.P.) and Public Health Sciences (M.G.), The University of Chicago, IL; and CMO and cofounder (S.C.J.), Harbor Health, Austin, TX
| | - Shyam Prabhakaran
- From the Departments of Neurology (J.R.B., S.P.) and Public Health Sciences (M.G.), The University of Chicago, IL; and CMO and cofounder (S.C.J.), Harbor Health, Austin, TX
| | - S Claiborne Johnston
- From the Departments of Neurology (J.R.B., S.P.) and Public Health Sciences (M.G.), The University of Chicago, IL; and CMO and cofounder (S.C.J.), Harbor Health, Austin, TX
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10
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Naveed H, Akhtar N, Al-Jerdi S, Uy RT, Joseph S, Morgan D, Babu B, Shanthi S, Shuaib A. Appropriate use of antiplatelet medications following transient ischemic attacks and stroke: a 9-year study from the Middle East. Front Neurol 2023; 14:1269292. [PMID: 38020628 PMCID: PMC10666165 DOI: 10.3389/fneur.2023.1269292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Background and purpose Guidelines recommend that patients with high-risk TIAs and minor strokes presenting within 1-3 days from onset should be offered dual antiplatelet therapy (DAPT). There are little data on real-world adherence to these recommendations. We evaluated the appropriateness of DAPT use in TIA and stroke patients in a prospective database. Methods The Qatar Stroke Database began the enrollment of patients with TIAs and acute stroke in 2014 and currently has ~16,000 patients. For this study, we evaluated the rates of guideline-adherent use of antiplatelet treatment at the time of discharge in patients with TIAs and stroke. TIAs were considered high-risk with an ABCD2 score of 4, and a minor stroke was defined as an NIHSS of 3. Patient demographics, clinical features, risk factors, previous medications, imaging and laboratory investigations, final diagnosis, discharge medications, and discharge and 90-day modified Rankin Scale (mRS) were analyzed. Results After excluding patients with ICH, mimics, and rare secondary causes, 8,082 patients were available for final analysis (TIAs: 1,357 and stroke: 6,725). In high-risk TIAs, 282 of 666 (42.3%) patients were discharged on DAPT. In patients with minor strokes, 1,207 of 3,572 (33.8%) patients were discharged on DAPT. DAPT was inappropriately offered to 238 of 691 (34.4%) low-risk TIAs and 809 of 3,153 (25.7%) non-minor stroke patients. Conclusion This large database of prospectively collected patients with TIAs and stroke shows that, unfortunately, despite several guidelines, a large majority of patients with TIAs and stroke are receiving inappropriate antiplatelet treatment at discharge from the hospital. This requires urgent attention and further investigation.
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Affiliation(s)
- Hiba Naveed
- Department of Medical Education, Weill Cornell College of Medicine, Doha, Qatar
| | - Naveed Akhtar
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Salman Al-Jerdi
- Department of Medical Education, Weill Cornell College of Medicine, Doha, Qatar
| | - Ryan Ty Uy
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Sujatha Joseph
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Deborah Morgan
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Blessy Babu
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Shobana Shanthi
- The Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ashfaq Shuaib
- Neurology Division, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Tan H. The mediating role of anxiety in disease uncertainty and acute stress in acute ischaemic stroke patients in the post-epidemic era. Front Psychiatry 2023; 14:1218390. [PMID: 37915800 PMCID: PMC10616834 DOI: 10.3389/fpsyt.2023.1218390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/01/2023] [Indexed: 11/03/2023] Open
Abstract
Objective To analyse the influencing factors of anxiety, disease uncertainty and acute stress response in patients with acute ischaemic stroke, and to verify the mediating role of anxiety in the post-epidemic era. Methods 240 patients with acute ischaemic stroke were selected from a tertiary hospital in Wuhan City and investigated by questionnaire and convenience sampling methods. Results The total anxiety score, disease uncertainty and acute stress reaction were at moderate levels. Anxiety was positively correlated with illness uncertainty, and anxiety and acute stress response were negatively correlated. Multiple linear regression analysis showed that Sickness uncertainty, acute stress response, age, and work status influenced anxiety. Anxiety mediated the prediction of Sickness uncertainty and acute stress response, with the mediating effect accounting for 35.6% of the total effect. Conclusion Disease uncertainty in patients with acute ischaemic stroke in the post-epidemic era directly affects the acute stress response and indirectly through anxiety.
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Affiliation(s)
- Hui Tan
- Quzhou TCM Hospital at the Junction of Four Provinces Affiliated to Zhejiang Chinese Medical University/Quzhou Hospital of Traditional Chinese Medicine, Quzhou, China
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12
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Han M, Jia W, Wu Y, Kuang J, Tu J, Yin S, Chen J, Zhang X, Li J, Chen Y, Wu B, Yi Y. Short-term efficacy and safety of personalized antiplatelet therapy for patients with acute ischaemic stroke or transient ischaemic attack: A randomized clinical trial. Br J Clin Pharmacol 2023; 89:2813-2824. [PMID: 37159861 DOI: 10.1111/bcp.15775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 04/07/2023] [Accepted: 04/22/2023] [Indexed: 05/11/2023] Open
Abstract
AIMS The aim of this study was to determine whether the testing strategy for clopidogrel and/or aspirin resistance using CYP2C19 genotyping or urinary 11-dhTxB2 testing has an impact on clinical outcomes. METHODS A multicentre, randomized, controlled trial was conducted at 14 centres in China from 2019 to 2021. For the intervention group, a specific antiplatelet strategy was assigned based on the CYP2C19 genotype and 11-dhTxB2, a urinary metabolite of aspirin, and the control group received nonguided (ie, standard of care) treatment. 11-dhTXB2 is a thromboxane A2 metabolite that can help quantify the effects of resistance to aspirin in individuals after ingestion. The primary efficacy outcome was new stroke, the secondary efficacy outcome was a poor functional prognosis (a modified Rankin scale score ≥3), and the primary safety outcome was bleeding, all within the 90-day follow-up period. RESULTS A total of 2815 patients were screened and 2663 patients were enrolled in the trial, with 1344 subjects assigned to the intervention group and 1319 subjects assigned to the control group. A total of 60.1% were carriers of the CYP2C19 loss-of-function allele (*2, *3) and 8.71% tested positive for urinary 11-dhTxB2- indicating aspirin resistance in the intervention group. The primary outcome was not different between the intervention and control groups (P = .842). A total of 200 patients (14.88%) in the intervention group and 240 patients (18.20%) in the control group had a poor functional prognosis (hazard ratio 0.77, 95% confidence interval [CI] 0.63 to 0.95, P = .012). Bleeding events occurred in 49 patients (3.65%) in the intervention group and 72 patients (5.46%) in the control group (hazard ratio 0.66, 95% CI 0.45 to 0.95, P = .025). CONCLUSIONS Personalized antiplatelet therapy based on the CYP2C19 genotype and 11-dhTxB2 levels was associated with favourable neurological function and reduced bleeding risk in acute ischaemic stroke and transient ischaemic attack patients. The results may help support the role of CYP2C19 genotyping and urinary 11-dhTxB2 testing in the provision of precise clinical treatment.
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Affiliation(s)
- Mengqi Han
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Weijie Jia
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Yifan Wu
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Jie Kuang
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Jianglong Tu
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
| | - Shujuan Yin
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Jibiao Chen
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Xiaolin Zhang
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Jingyi Li
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Yongsen Chen
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Bin Wu
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
- Jiangxi Provincial Key Laboratory of Preventive Medicine, School of Public Health, Nanchang University, Nanchang, P.R. China
| | - Yingping Yi
- Department of Medical Big Data Center, The Second Affiliated Hospital of Nanchang University, Nanchang, P.R. China
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Chen HS, Cui Y, Zhou ZH, Zhang H, Wang LX, Wang WZ, Shen LY, Guo LY, Wang EQ, Wang RX, Han J, Dong YL, Li J, Lin YZ, Yang QC, Zhang L, Li JY, Wang J, Xia L, Ma GB, Lu J, Jiang CH, Huang SM, Wan LS, Piao XY, Li Z, Li YS, Yang KH, Wang DL, Nguyen TN. Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial. JAMA 2023; 329:2135-2144. [PMID: 37367978 PMCID: PMC10300686 DOI: 10.1001/jama.2023.7827] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 04/22/2023] [Indexed: 06/28/2023]
Abstract
Importance Intravenous thrombolysis is increasingly used in patients with minor stroke, but its benefit in patients with minor nondisabling stroke is unknown. Objective To investigate whether dual antiplatelet therapy (DAPT) is noninferior to intravenous thrombolysis among patients with minor nondisabling acute ischemic stroke. Design, Setting, and Participants This multicenter, open-label, blinded end point, noninferiority randomized clinical trial included 760 patients with acute minor nondisabling stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤5, with ≤1 point on the NIHSS in several key single-item scores; scale range, 0-42). The trial was conducted at 38 hospitals in China from October 2018 through April 2022. The final follow-up was on July 18, 2022. Interventions Eligible patients were randomized within 4.5 hours of symptom onset to the DAPT group (n = 393), who received 300 mg of clopidogrel on the first day followed by 75 mg daily for 12 (±2) days, 100 mg of aspirin on the first day followed by 100 mg daily for 12 (±2) days, and guideline-based antiplatelet treatment until 90 days, or the alteplase group (n = 367), who received intravenous alteplase (0.9 mg/kg; maximum dose, 90 mg) followed by guideline-based antiplatelet treatment beginning 24 hours after receipt of alteplase. Main Outcomes and Measures The primary end point was excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 (range, 0-6), at 90 days. The noninferiority of DAPT to alteplase was defined on the basis of a lower boundary of the 1-sided 97.5% CI of the risk difference greater than or equal to -4.5% (noninferiority margin) based on a full analysis set, which included all randomized participants with at least 1 efficacy evaluation, regardless of treatment group. The 90-day end points were assessed in a blinded manner. A safety end point was symptomatic intracerebral hemorrhage up to 90 days. Results Among 760 eligible randomized patients (median [IQR] age, 64 [57-71] years; 223 [31.0%] women; median [IQR] NIHSS score, 2 [1-3]), 719 (94.6%) completed the trial. At 90 days, 93.8% of patients (346/369) in the DAPT group and 91.4% (320/350) in the alteplase group had an excellent functional outcome (risk difference, 2.3% [95% CI, -1.5% to 6.2%]; crude relative risk, 1.38 [95% CI, 0.81-2.32]). The unadjusted lower limit of the 1-sided 97.5% CI was -1.5%, which is larger than the -4.5% noninferiority margin (P for noninferiority <.001). Symptomatic intracerebral hemorrhage at 90 days occurred in 1 of 371 participants (0.3%) in the DAPT group and 3 of 351 (0.9%) in the alteplase group. Conclusions and Relevance Among patients with minor nondisabling acute ischemic stroke presenting within 4.5 hours of symptom onset, DAPT was noninferior to intravenous alteplase with regard to excellent functional outcome at 90 days. Trial Registration ClinicalTrials.gov Identifier: NCT03661411.
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Affiliation(s)
- Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Zhong-He Zhou
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Hong Zhang
- Department of Neurology, Liaoning Health Industry Group Fukuang General Hospital, Fushun, China
| | - Li-Xia Wang
- Department of Neurology, Tieling Central Hospital, Tieling, China
| | - Wei-Zhong Wang
- Department of Neurology, Dandong Central Hospital, Dandong, China
| | - Li-Ying Shen
- Department of Neurology, Tieling County Central Hospital, Tieling, China
| | - Li-Yan Guo
- Department of Neurology, Fushun Second Hospital, Fushun, China
| | - Er-Qiang Wang
- Department of Neurology, The Fuqing Affiliated Hospital of Fujian Medical University, Fuqing, China
| | - Rui-Xian Wang
- Department of Neurology, The Tianjin Beichen Traditional Chinese Medicine Hospital, Tianjin, China
| | - Jing Han
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Yu-Ling Dong
- Department of Neurology, Chaoyang Second Hospital, Chaoyang, China
| | - Jing Li
- Department of Neurology, Donggang Central Hospital, Donggang, China
| | - Yong-Zhong Lin
- Department of Neurology, The Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Qing-Cheng Yang
- Department of Neurology, Anyang People‘s Hospital, Anyang, China
| | - Li Zhang
- Department of Neurology, Suizhong Central Hospital, Suizhong, China
| | - Jing-Yu Li
- Department of Neurology, Chinese People’s Liberation Army 967 Hospital, Dalian, China
| | - Jin Wang
- Department of Neurology, Huludao Central Hospital, Huludao, China
| | - Lei Xia
- Department of Neurology, Zhoukou Central Hospital, Zhoukou, China
| | - Guang-Bin Ma
- Department of Neurology, Haicheng Traditional Chinese Medicine Hospital, Haicheng, China
| | - Jiang Lu
- Department of Neurology, The Dalinghe Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Chang-Hao Jiang
- Department of Neurology, Lvshunkou Traditional Chinese Medicine Hospital, Lvshunkou, China
| | - Shu-Man Huang
- Department of Neurology, Dawa District People‘s Hospital, Panjin, China
| | - Li-Shu Wan
- Department of Neurology, Dandong First Hospital, Dandong, China
| | - Xiang-Yu Piao
- Department of Neurology, The Zhongshan Affiliated Hospital of Dalian University, Dalian, China
| | - Zhuo Li
- Department of Neurology, Panjin Central Hospital, Panjin, China
| | - Yan-Song Li
- Department of Neurology, Army Hospital of Northern Theatre Command, Shenyang, China
| | - Kui-Hua Yang
- Department of Neurology, Liaoyang Second People’s Hospital, Liaoyang, China
| | - Duo-Lao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Thanh N. Nguyen
- Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
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Chen PL, Chen YJ, Chung CP, Seak CJ, Jeng JS, Hsieh MJ, Lien LM, Chen JH, Chen YW, Chiu TF, Lee JT, Ng CJ. Dual Antiplatelet Therapy in the Management of Acute Minor Ischemic Stroke and High-Risk Transient Ischemic Attack: An Expert Consensus Statement From Taiwan Stroke Society and Taiwan Society of Emergency Medicine. J Acute Med 2022; 12:85-95. [PMID: 36313610 PMCID: PMC9561483 DOI: 10.6705/j.jacme.202209_12(3).0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 07/24/2022] [Indexed: 06/16/2023]
Abstract
The aim of this review is to achieve a consensus between Taiwan Stroke Society (TSS) and Taiwan Society of Emergency Medicine (TSEM) to manage acute non-cardioembolic minor ischemic stroke (MIS) and high-risk transient ischemic attack (TIA). The methodology is to review the recent findings from clinical trials of dual antiplatelet therapy (DAPT) from 2010 to 2021 and updates in clinical practice guidelines from 2018 to 2022 for non-cardioembolic MIS/TIA management at the acute stage. Four leading clinical studies, CHANCE, POINT, THALES, and CHANCE-2 along with other relevant studies introducing DAPT, are discussed in this review. The risk-benefit profile between stroke recurrence reduction and major bleeding increase is also elucidated. TSS and TSEM concluded that for patients presenting with non-cardioembolic MIS or high-risk TIA who did not receive intravenous alteplase, initiation of DAPT within 24 hours after stroke onset and continued up to 21 days, followed by antiplatelet monotherapy, is effective in reducing recurrent ischemic stroke for a period of up to 90 days.
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Affiliation(s)
- Po-Lin Chen
- Neurological Institute Division of Neurology Taichung Veterans General Hospital, Taichung Taiwan
| | - Ying-Ju Chen
- Taipei Veterans General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Chih-Ping Chung
- Neurological Institute Department of Neurology Taipei Veterans General Hospital, Taipei Taiwan
| | - Chen-June Seak
- New Taipei Municipal Tucheng Hospital Department of Emergency Medicine New Taipei City Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Jiann-Shing Jeng
- National Taiwan University Hospital Department of Neurology and Stroke Center Taipei Taiwan
| | - Ming-Ju Hsieh
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
| | - Li-Ming Lien
- Shin Kong Wu Ho-Su Memorial Hospital Department of Neurology Taipei Taiwan
| | - Jiann-Hwa Chen
- Cathay General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Yu-Wei Chen
- Landseed International Hospital Department of Neurology Taoyuan Taiwan
| | - Te-Fa Chiu
- China Medical University Hospital Department of Emergency Medicine Taichung Taiwan
| | - Jiunn-Tay Lee
- Tri-Service General Hospital Department of Neurology National Defense Medical Center, Taipei Taiwan
| | - Chip-Jin Ng
- Chang Gung University College of Medicine Taoyuan Taiwan
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
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15
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Kim AS. Optimizing the Time Course of Risks and Benefits of Acute Dual Antiplatelet Therapy for Stroke Prevention. JAMA Neurol 2022; 79:736-738. [PMID: 35727575 DOI: 10.1001/jamaneurol.2022.1230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anthony S Kim
- UCSF Weill Institute for Neurosciences, Department of Neurology, University of California, San Francisco, San Francisco
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16
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Pan Y, Meng X, Jin A, Johnston SC, Li H, Bath PM, Xie X, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Yang H, Cheng J, Wang Z, Wang Y. Time Course for Benefit and Risk With Ticagrelor and Aspirin in Individuals With Acute Ischemic Stroke or Transient Ischemic Attack Who Carry CYP2C19 Loss-of-Function Alleles: A Secondary Analysis of the CHANCE-2 Randomized Clinical Trial. JAMA Neurol 2022; 79:739-745. [PMID: 35727586 DOI: 10.1001/jamaneurol.2022.1457] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Dual antiplatelet therapy (DAPT) with ticagrelor and aspirin has been found to be effective for secondary prevention after minor ischemic stroke or transient ischemic attack (TIA) in individuals who carry CYP2C19 loss-of-function (LOF) alleles; however, uncertainties remain about the time course of benefit and risk with ticagrelor and aspirin in these patients. Objective To obtain time-course estimates of efficacy and risk with ticagrelor and aspirin after minor stroke or TIA in individuals with CYP2C19 LOF alleles. Design, Setting, and Participants The Ticagrelor or Clopidogrel With Aspirin in High-risk Patients With Acute Nondisabling Cerebrovascular Events II (CHANCE-2) randomized clinical trial enrolled patients 40 years and older from 202 hospitals in China with acute minor stroke or TIA who carried CYP2C19 LOF alleles between September 23, 2019, and March 22, 2021, and were followed up for 90 days. All 6412 patients enrolled in the CHANCE-2 trial were included in this secondary analysis. Data were analyzed in October 2021. Interventions Ticagrelor (180 mg on day 1 followed by 90 mg twice daily on days 2-90) or clopidogrel (300 mg on day 1 followed by 75 mg daily on days 2-90). All patients received aspirin (75-300 mg on day 1 followed by 75 mg daily for 21 days). Main Outcomes and Measures The efficacy outcome was major ischemic event, defined as the composite of ischemic stroke or nonhemorrhagic death. Safety outcomes included moderate to severe bleeding and any bleeding. Results A total of 6412 patients were included (3205 in the ticagrelor and aspirin group and 3207 in the clopidogrel and aspirin group). The median (IQR) age was 65 (57-71) years, and 4242 patients (66%) were men. The reduction of major ischemic events with ticagrelor and aspirin predominately occurred in the first week (absolute risk reduction, 1.34%; 95% CI, 0.29 to 2.39) and attenuated but remained in the next 3 weeks (absolute risk reduction in the second week, 0.11%; 95% CI, -0.24 to 0.45; absolute risk reduction in the third week, 0.14%; 95% CI, -0.11 to 0.38; absolute risk reduction in the fourth week, 0.04%; 95% CI, -0.18 to 0.25). The risk of moderate to severe bleeding was consistently low in the ticagrelor and aspirin group. The absolute increase in any bleeding seen in the first week (0.87%; 95% CI, 0.25 to 1.50) remained in the next 3 weeks (absolute increase in the second week, 1.21%; 95% CI, 0.75 to 1.68; absolute increase in the third week, 0.33%; 95% CI, -0.05 to 0.72; absolute increase in the fourth week, 0.23%; 95% CI, -0.03 to 0.49). Conclusion and Relevance Among patients with minor stroke or TIA who carried CYP2C19 LOF alleles, benefit with ticagrelor and aspirin was present predominately in the first week, with additional small benefit accruing in the next 2 weeks.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Aoming Jin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongqin Yang
- Department of Neurology, Jiyuan Hospital of Traditional Chinese Medicine, Henan, China
| | - Jiwei Cheng
- Department of Neurology, Putuo District Central Hospital, Shanghai, China
| | - Zhimin Wang
- Department of Neurology, Taizhou First People's Hospital, Zhejiang, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
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Mahajan C, Kapoor I, Prabhakar H. A Narrative Review on Translational Research in Acute Brain Injury. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2022. [DOI: 10.1055/s-0042-1744399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThere has been a constant endeavor to reduce the mortality and morbidity associated with acute brain injury. The associated complex mechanisms involving biomechanics, markers, and neuroprotective drugs/measures have been extensively studied in preclinical studies with an ultimate aim to improve the patients' outcomes. Despite such efforts, only few have been successfully translated into clinical practice. In this review, we shall be discussing the major hurdles in the translation of preclinical results into clinical practice. The need is to choose an appropriate animal model, keeping in mind the species, age, and gender of the animal, choosing suitable outcome measures, ensuring quality of animal trials, and carrying out systematic review and meta-analysis of experimental studies before proceeding to human trials. The interdisciplinary collaboration between the preclinical and clinical scientists will help to design better, meaningful trials which might help a long way in successful translation. Although challenging at this stage, the advent of translational precision medicine will help the integration of mechanism-centric translational medicine and patient-centric precision medicine.
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Affiliation(s)
- Charu Mahajan
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Indu Kapoor
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Natale P, Palmer SC, Saglimbene VM, Ruospo M, Razavian M, Craig JC, Jardine MJ, Webster AC, Strippoli GF. Antiplatelet agents for chronic kidney disease. Cochrane Database Syst Rev 2022; 2:CD008834. [PMID: 35224730 PMCID: PMC8883339 DOI: 10.1002/14651858.cd008834.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet agents may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. This is an update of a review first published in 2013. OBJECTIVES To evaluate the benefits and harms of antiplatelet agents in people with any form of CKD, including those with CKD not receiving renal replacement therapy, patients receiving any form of dialysis, and kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 13 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials of any antiplatelet agents versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated. DATA COLLECTION AND ANALYSIS Four authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data were pooled using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 113 studies, enrolling 51,959 participants; 90 studies (40,597 CKD participants) compared an antiplatelet agent with placebo or no treatment, and 29 studies (11,805 CKD participants) directly compared one antiplatelet agent with another. Fifty-six new studies were added to this 2021 update. Seven studies originally excluded from the 2013 review were included, although they had a follow-up lower than two months. Random sequence generation and allocation concealment were at low risk of bias in 16 and 22 studies, respectively. Sixty-four studies reported low-risk methods for blinding of participants and investigators; outcome assessment was blinded in 41 studies. Forty-one studies were at low risk of attrition bias, 50 studies were at low risk of selective reporting bias, and 57 studies were at low risk of other potential sources of bias. Compared to placebo or no treatment, antiplatelet agents probably reduces myocardial infarction (18 studies, 15,289 participants: RR 0.88, 95% CI 0.79 to 0.99, I² = 0%; moderate certainty). Antiplatelet agents has uncertain effects on fatal or nonfatal stroke (12 studies, 10.382 participants: RR 1.01, 95% CI 0.64 to 1.59, I² = 37%; very low certainty) and may have little or no effect on death from any cause (35 studies, 18,241 participants: RR 0.94, 95 % CI 0.84 to 1.06, I² = 14%; low certainty). Antiplatelet therapy probably increases major bleeding in people with CKD and those treated with haemodialysis (HD) (29 studies, 16,194 participants: RR 1.35, 95% CI 1.10 to 1.65, I² = 12%; moderate certainty). In addition, antiplatelet therapy may increase minor bleeding in people with CKD and those treated with HD (21 studies, 13,218 participants: RR 1.55, 95% CI 1.27 to 1.90, I² = 58%; low certainty). Antiplatelet treatment may reduce early dialysis vascular access thrombosis (8 studies, 1525 participants) RR 0.52, 95% CI 0.38 to 0.70; low certainty). Antiplatelet agents may reduce doubling of serum creatinine in CKD (3 studies, 217 participants: RR 0.39, 95% CI 0.17 to 0.86, I² = 8%; low certainty). The treatment effects of antiplatelet agents on stroke, cardiovascular death, kidney failure, kidney transplant graft loss, transplant rejection, creatinine clearance, proteinuria, dialysis access failure, loss of primary unassisted patency, failure to attain suitability for dialysis, need of intervention and cardiovascular hospitalisation were uncertain. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, including prasugrel, ticagrelor, different doses of clopidogrel, abciximab, defibrotide, sarpogrelate and beraprost. AUTHORS' CONCLUSIONS Antiplatelet agents probably reduced myocardial infarction and increased major bleeding, but do not appear to reduce all-cause and cardiovascular death among people with CKD and those treated with dialysis. The treatment effects of antiplatelet agents compared with each other are uncertain.
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Affiliation(s)
- Patrizia Natale
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Mona Razavian
- Renal and Metabolic Division, The George Institute for Global Health, Newtown, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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The Clinical Features of In-Hospital Recurrence in Acute Ischaemic Stroke Patients over Time: A Real-World Observation at a Single Center. Brain Sci 2022; 12:brainsci12020123. [PMID: 35203887 PMCID: PMC8869764 DOI: 10.3390/brainsci12020123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/14/2022] [Accepted: 01/15/2022] [Indexed: 12/10/2022] Open
Abstract
Acute ischaemic stroke (AIS) has a high risk of recurrence, particularly in the early stage. Our study aimed to assess the clinical characteristics and risk factors of in-hospital ischaemic recurrence in AIS patients in different periods. This study was a retrospective, single-center analysis. The patients were divided into two stages based on their admission time. The primary endpoint was recurrent stroke during hospitalization. In total, 978 patients in Stage 1 and 1047 patients in Stage 2 were included in this study. The in-hospital recurrence rate in Stage 1 was 5.9%, while that in Stage 2 was 4.0% (p = 0.046). A recurrence rate reduction mainly occurred in the minor stroke and large-artery atherosclerosis (LAA) stroke patients. Infection was an independent risk factor despite amelioration by antiplatelet therapy (p < 0.001). Diabetes patients also had a higher risk of in-hospital ischaemic recurrence among the minor stroke and large-artery atherosclerosis patients. A positive attitude towards antiplatelet therapy failed to completely halt recurrence of the disease. In conclusion, the rate of in-hospital ischaemic recurrence in AIS patients showed a decreasing trend over time, especially in the minor stroke and large-artery atherosclerosis stroke patients. Infection and diabetes were associated with a higher risk of stroke recurrence.
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20
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Bulwa ZB, Mendelson SJ, Brorson JR. Acute Secondary Prevention of Ischemic Stroke: Overlooked No Longer. Front Neurol 2021; 12:701168. [PMID: 34566845 PMCID: PMC8460867 DOI: 10.3389/fneur.2021.701168] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/28/2021] [Indexed: 12/12/2022] Open
Abstract
Recent studies of interventions initiated acutely following onset of minor ischemic stroke or transient ischemic attack (TIA) have disclosed early stroke recurrence rates that are substantially higher than long-term recurrence rates and that can be reduced by acute antiplatelet treatment interventions. These observations, bolstered by analysis based on kinetic modeling of the time course of recurrence following initial events, suggest that acute stroke patients experience an underlying vulnerable state that quickly transitions to a more stable state. Some evidence also supports the benefits of early treatment with direct-acting oral anticoagulants in cardioembolic stroke and of continuation or early initiation of statin therapy in atherosclerotic stroke. Treatment of ischemic stroke should address the transient vulnerable state that follows the initial event, employing measures aiming to avert early recurrence of thromboembolism and to promote stabilization of vulnerable arterial plaque. These measures constitute acute secondary prevention following ischemic stroke.
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Affiliation(s)
- Zachary B Bulwa
- Department of Neurology, Rush University Medical Center, Chicago, IL, United States
| | - Scott J Mendelson
- Department of Neurology, The University of Chicago, Chicago, IL, United States
| | - James R Brorson
- Department of Neurology, The University of Chicago, Chicago, IL, United States
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21
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Abstract
PURPOSE OF REVIEW Antiplatelet therapy remains the standard of care in secondary stroke prevention for non-cardioembolic ischemic stroke and transient ischemic attack. We aim to examine the use of antiplatelet agents in secondary prevention through highlighting relevant clinical trials and meta-analyses as well as providing commentary regarding our practice. RECENT FINDINGS In the POINT and CHANCE trials, dual antiplatelet therapy reduced recurrent stroke compared to aspirin monotherapy. Sub-analyses of these trials suggest that genetic polymorphisms could play a role in diminishing the effectiveness of clopidogrel. Similarly, THALES demonstrated better outcomes with ticagrelor-aspirin combination therapy over aspirin monotherapy. Combination antiplatelet therapy with aspirin and the P2Y12 inhibitors, clopidogrel and ticagrelor, reduced stroke recurrence in those presenting with mild ischemic stroke or high risk TIA. Genetic polymorphisms may play a role in determining the appropriate regimen. Questions remain regarding the optimal duration of combination antiplatelet therapy for various stroke etiologies.
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22
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Pan Y, Elm JJ, Li H, Easton JD, Wang Y, Farrant M, Meng X, Kim AS, Zhao X, Meurer WJ, Liu L, Dietrich D, Wang Y, Johnston SC. Outcomes Associated With Clopidogrel-Aspirin Use in Minor Stroke or Transient Ischemic Attack: A Pooled Analysis of Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events (CHANCE) and Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trials. JAMA Neurol 2021; 76:1466-1473. [PMID: 31424481 DOI: 10.1001/jamaneurol.2019.2531] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Dual antiplatelet therapy with clopidogrel and aspirin is effective for secondary prevention after minor ischemic stroke or transient ischemic attack (TIA). Uncertainties remained about the optimal duration of dual antiplatelet therapy for minor stroke or TIA. Objective To obtain precise estimates of efficacy and risk of dual antiplatelet therapy after minor ischemic stroke or TIA. Design, Setting, and Participants This analysis pooled individual patient-level data from 2 large-scale randomized clinical trials that evaluated clopidogrel-aspirin as a treatment to prevent stroke after a minor stroke or high-risk TIA. The Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events (CHANCE) trial enrolled patients at 114 sites in China from October 1, 2009, to July 30, 2012. The Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial enrolled patients at 269 international sites from May 28, 2010, to December 19, 2017. Both were followed up for 90 days. Data analysis occurred from November 2018 to May 2019. Interventions In the 2 trials, patients with minor stroke or high-risk TIA were randomized to clopidogrel-aspirin or aspirin alone within 12 hours (POINT) or 24 hours (CHANCE) of symptom onset. Main Outcomes and Measures The primary efficacy outcome was a major ischemic event (ischemic stroke, myocardial infarction, or death from ischemic vascular causes). The primary safety outcome was major hemorrhage. Results The study enrolled 5170 patients (CHANCE) and 4881 patients (POINT). Analysis included individual data from 10 051 patients (5016 in the clopidogrel-aspirin treatment group and 5035 in the control group) with a median age of 63.2 (interquartile range, 55.0-72.9) years; 6106 patients (60.8%) were male. Clopidogrel-aspirin treatment reduced the risk of major ischemic events at 90 days compared with aspirin alone (328 of 5016 [6.5%] vs 458 of 5035 [9.1%]; hazard ratio [HR], 0.70 [95% CI, 0.61-0.81]; P < .001), mainly within the first 21 days (263 of 5016 [5.2%] vs 391 of 5035 [7.8%]; HR, 0.66 [95% CI, 0.56-0.77]; P < .001), but not from day 22 to day 90. No evidence of heterogeneity of treatment outcome across trials or prespecified subgroups was observed. Major hemorrhages were more frequent in the clopidogrel-aspirin group, but the difference was nonsignificant. Conclusions and Relevance In this analysis of the POINT and CHANCE trials, the benefit of dual antiplatelet therapy appeared to be confined to the first 21 days after minor ischemic stroke or high-risk TIA.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jordan J Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Mary Farrant
- Department of Neurology, University of California, San Francisco
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Anthony S Kim
- Department of Neurology, University of California, San Francisco
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan, Ann Arbor.,Department of Neurology, University of Michigan, Ann Arbor
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | | | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Brown DL, Levine DA, Albright K, Kapral MK, Leung LY, Reeves MJ, Sico J, Strong B, Whiteley WN. Benefits and Risks of Dual Versus Single Antiplatelet Therapy for Secondary Stroke Prevention: A Systematic Review for the 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. Stroke 2021; 52:e468-e479. [PMID: 34024115 DOI: 10.1161/str.0000000000000377] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) after ischemic stroke or transient ischemic attack may reduce recurrent stroke but also increase severe bleeding compared with single antiplatelet therapy (SAPT). The American Heart Association/American Stroke Association convened an evidence review committee to perform a systematic review and meta-analysis of the benefits and risks of DAPT compared with SAPT for secondary ischemic stroke prevention. METHODS The Medline, Embase, and Cochrane databases were searched on December 5, 2019, to identify phase III or IV randomized controlled trials (n≥100) from December 1999 to December 2019. We calculated unadjusted relative risks (RRs) and performed meta-analyses of studies based on the duration of treatment (short [≤90 days] versus long [>90 days]). RESULTS Three short-duration randomized controlled trials were identified that enrolled mostly patients with minor stroke or high risk transient ischemic attack. In these trials, DAPT, compared with SAPT, was associated with a lower 90-day risk of recurrent ischemic stroke (pooled RR, 0.68 [95% CI, 0.55-0.83], I 2=37.1%). There was no significant increase in major bleeding with DAPT in short-duration trials (pooled RR, 1.88 [95% CI, 0.93-3.83], I 2=8.9%). In 2 long-duration treatment randomized controlled trials (mean treatment duration, 18-40 months), DAPT was not associated with a significant reduction in recurrent ischemic stroke (pooled RR, 0.89 [95% CI, 0.79-1.02], I 2=1.4%), but was associated with a higher risk of major bleeding (pooled RR, 2.42 [95% CI, 1.37-4.30], I 2=75.5%). CONCLUSIONS DAPT was more effective than SAPT for prevention of secondary ischemic stroke when initiated early after the onset of minor stroke/high-risk transient ischemic attack and treatment duration was <90 days. However, when the treatment duration was longer and initiated later after stroke or transient ischemic attack onset, DAPT was not more effective than SAPT for ischemic stroke prevention and it increased the risk of bleeding.
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Risk of Early Bleeding with Dual Antiplatelet Therapy in Acute Stroke and Transient Ischemic Attack Regardless of NIHSS Admission. J Stroke Cerebrovasc Dis 2021; 30:105677. [DOI: 10.1016/j.jstrokecerebrovasdis.2021.105677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/10/2021] [Accepted: 02/06/2021] [Indexed: 11/18/2022] Open
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Sun J, Leng P, Sun C, Xu W, Zhao Z, Li X, Zhang X, Li J. Should CYP2C19 Genotyping Be Recommended as a Straight Forward Approach to Optimize Clopidogrel Utilization in Patients with Ischemic Stroke Complicated by Type 2 Diabetes Mellitus? Pharmgenomics Pers Med 2020; 13:645-653. [PMID: 33262635 PMCID: PMC7698285 DOI: 10.2147/pgpm.s279719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/30/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There have been few studies on CYP2C19 genotypes and clopidogrel response associated with ischemic stroke (IS), especially IS complicated by type 2 diabetes mellitus (T2DM). This study aimed to investigate the possible association between CYP2C19 polymorphisms and high on-treatment platelet reactivity (HTPR) in IS patients with T2DM in China. PATIENTS AND METHODS A total of 426 consecutive IS patients with T2DM were enrolled in this case-control study and they were divided into HTPR group and non-HTPR group according to the ADP-induced platelet inhibition (PIADP) assessed by thromboelastography (TEG). Genotypes were detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Various clinical and demographic data were also recorded. The association between CYP2C19 genetic variants and platelet function was assessed. RESULTS Carriers of CYP2C19*2 heterozygous and mutant homozygous genotypes showed significantly lower PIADP than non-carriers (27.2% vs 38.3%, p < 0.001; 27.41% vs 38.3%, p = 0.012, respectively). Compared with the control group, the CYP2C19*2 A allele was more frequent in the HTPR group (34.51% vs 25.82%, p = 0.002). The carriage of CYP2C19*2 mutant allele was significantly associated with increased risk of HTPR (odds ratio (OR) = 1.94, 95% confidence interval (CI) = 1.32-2.85). There was no significant correlation between CYP2C19*3 or *17 genotypes and HTPR risk. CONCLUSION CYP2C19*2 mutant allele was associated with attenuated platelet response to clopidogrel and increased risk of HTPR in IS patients with T2DM, suggesting that CYP2C19*2 polymorphism might be an important predictor of HTPR in this high-risk population.
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Affiliation(s)
- Jialin Sun
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Ping Leng
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Chen Sun
- Department of Pharmacy, Qingdao Municipal Hospital, Qingdao266003, Shandong, People’s Republic of China
| | - Wen Xu
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Zhenhuan Zhao
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Xiao Li
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Xiaolei Zhang
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Jing Li
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
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Wang H, Li X, Liu C, Huang S, Liang C, Zhang M. Effects of Oral Antiplatelet Agents and Tirofiban on Functional Outcomes of Patients with Non-Disabling Minor Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 29:104829. [PMID: 32689578 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 03/20/2020] [Accepted: 03/22/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Over half of patients with acute ischemic stroke present with minor neurologic deficits. We investigated the effects of oral antiplatelet agents vs. tirofiban, a highly selective GP IIb/IIIa antiplatelet drug, on functional outcomes of stroke patients with non-disabling neurologic deficits. METHODS This retrospective study analyzed data of 125 patients with minor stroke who had National Institutes of Health Stroke Scale (NIHSS) scores of 5 or less within 6 hours of stroke symptom onset between January 2010 and June 2018. All patients were selected from the Department of Neurology at the Third Affiliated Hospital of Army Medical University. There were 54 cases in each group after propensity score matching, in which patients received oral antiplatelet agents (n = 64) and tirofiban (n = 61). Safety outcomes were assessed by incident intracranial hemorrhage, systemic bleeding and death. Efficacy outcomes were assessed using the NIHSS score at 24 hrs, 7 days or at discharge, and clinical deterioration. The modified rankin scale (mRs) was assessed at 90 days. RESULTS No significant differences were found in the incidence of intracranial hemorrhage, systemic bleeding or death between groups (P>0.05). Although neurological function improved significantly in both groups, NIHSS scores were lower in the tirofiban group compared with those in the oral antiplatelet agents group at 24 hrs (1 versus 3, P = 0.000), 7 days or at discharge (0 versus 2, P = 0.000). The clinical deterioration rate was higher in the oral antiplatelet agents group than in the tirofiban group, but without significance (16.7% versus 5.6%, P = 0.126). Functional outcomes (mRs = 0) were more favorable in the tirofiban group than in the oral antiplatelet agents group (66.7% vs. 44.4%; adjusted odds ratio 3.32; 95% CI: 1.38-7.99; P = 0. 008). CONCLUSION Intravenous tirofiban seems to be safe and effective with more favorable functional outcomes than oral antiplatelet agents, suggesting that tirofiban is a viable treatment choice for selected patients with non-disabling minor acute ischemic stroke.
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Affiliation(s)
- Huan Wang
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoshu Li
- Department of Neurology, The Third Affiliated Hospital of Army Medical University, Chongqing, China
| | - Chengchun Liu
- Department of Neurology, The Third Affiliated Hospital of Army Medical University, Chongqing, China
| | - Shuhan Huang
- Department of Neurology, The Third Affiliated Hospital of Army Medical University, Chongqing, China
| | - Chunrong Liang
- Department of Neurology, The Third Affiliated Hospital of Army Medical University, Chongqing, China
| | - Meng Zhang
- Department of Neurology, The Third Affiliated Hospital of Army Medical University, Chongqing, China.
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Hou X, Chen H. Proposed antithrombotic strategy for acute ischemic stroke with large-artery atherosclerosis: focus on patients with high-risk transient ischemic attack and mild-to-moderate stroke. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:16. [PMID: 32055607 DOI: 10.21037/atm.2019.10.111] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
An effective antithrombotic strategy is required to prevent the recurrence and aggravation of large-artery atherosclerosis (LAA) stroke, especially in high-risk transient ischemic attack (TIA) and acute mild ischemic stroke. Based on clinical evidence, atherosclerotic thrombosis theory, antithrombotic treatment guidelines of acute myocardial infarction (AMI), and previous studies, a new antithrombotic strategy "early administration, enhanced therapy, combination therapy, short-term therapy, and sequential therapy" was proposed in this study. Multicenter randomized trials are needed in the future to verify the efficacy of the strategy.
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Affiliation(s)
- Xiaowen Hou
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Huisheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang 110016, China
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Del Brutto VJ, Chaturvedi S, Diener HC, Romano JG, Sacco RL. Antithrombotic Therapy to Prevent Recurrent Strokes in Ischemic Cerebrovascular Disease: JACC Scientific Expert Panel. J Am Coll Cardiol 2019; 74:786-803. [PMID: 31395130 PMCID: PMC7291776 DOI: 10.1016/j.jacc.2019.06.039] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 06/11/2019] [Accepted: 06/24/2019] [Indexed: 01/02/2023]
Abstract
Stroke survivors carry a high risk of recurrence. Antithrombotic medications are paramount for secondary prevention and thus crucial to reduce the overall stroke burden. Appropriate antithrombotic agent selection should be based on the best understanding of the physiopathological mechanism that led to the initial ischemic injury. Antiplatelet therapy is preferred for lesions characterized by atherosclerosis and endothelial injury, whereas anticoagulant agents are favored for cardiogenic embolism and highly thrombophilic conditions. Large randomized controlled trials have provided new data to support recommendations for the evidence-based use of antiplatelet agents and anticoagulant agents after stroke. In this review, the authors cover recent trials that have altered clinical practice, cite systematic reviews and meta-analyses, review evidence-based recommendations based on older landmark trials, and indicate where there are still evidence-gaps and new trials being conducted.
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Affiliation(s)
- Victor J Del Brutto
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Jose G Romano
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida.
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29
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Risks and benefits of clopidogrel–aspirin in minor stroke or TIA. Neurology 2019; 93:322. [DOI: 10.1212/wnl.0000000000007482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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30
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Gutierrez J, Lekic T. Letter re: Risks and benefits of clopidogrel-aspirin in minor stroke or TIA: Time course analysis of CHANCE. Neurology 2019; 89:2121. [PMID: 29133610 DOI: 10.1212/wnl.0000000000004654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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31
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Johnston SC, Elm JJ, Easton JD, Farrant M, Barsan WG, Kim AS, Lindblad AS, Palesch YY, Zurita KG, Albers GW, Cucchiara BL, Kleindorfer DO, Lutsep HL, Pearson C, Sethi P, Vora N. Time Course for Benefit and Risk of Clopidogrel and Aspirin After Acute Transient Ischemic Attack and Minor Ischemic Stroke. Circulation 2019; 140:658-664. [PMID: 31238700 DOI: 10.1161/circulationaha.119.040713] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND In patients with acute minor ischemic stroke or high-risk transient ischemic attack enrolled in the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke [POINT] Trial), the combination of clopidogrel and aspirin for 90 days reduced major ischemic events but increased major hemorrhage in comparison to aspirin alone. METHODS In a secondary analysis of POINT (N=4881), we assessed the time course for benefit and risk from the combination of clopidogrel and aspirin. The primary efficacy outcome was a composite of ischemic stroke, myocardial infarction, or ischemic vascular death. The primary safety outcome was major hemorrhage. Risks and benefits were estimated for delayed times of treatment initiation using left-truncated models. RESULTS Through 90 days, the rate of major ischemic events was initially high then decreased markedly, whereas the rate of major hemorrhage remained low but relatively constant throughout. With the use of a model-based approach, the optimal change point for major ischemic events was 21 days (0-21 days hazard ratio 0.65 for clopidogrel-aspirin versus aspirin; 95% CI, 0.50-0.85; P=0.0015, in comparison to 22-90 days hazard ratio, 1.38; 95% CI, 0.81-2.35; P=0.24). Models showed benefits of clopidogrel-aspirin for treatment delayed as long as 3 days after symptom onset. CONCLUSIONS The benefit of clopidogrel-aspirin occurs predominantly within the first 21 days, and outweighs the low, but ongoing risk of major hemorrhage. When considered with the results of the CHANCE trial (Clopidogrel in High-Risk Patients With Non-disabling Cerebrovascular Events), a similar trial treating with clopidogrel-aspirin for 21 days and showing no increase in major hemorrhage, these results suggest that limiting clopidogrel-aspirin use to 21 days may maximize benefit and reduce risk after high-risk transient ischemic attack or minor ischemic stroke. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00991029.
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Affiliation(s)
| | - Jordan J Elm
- Data Coordination Unit, Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.J.E., Y.Y.P.)
| | - J Donald Easton
- Department of Neurology, University of California, San Francisco (J.D.E., M.F., A.S.K., K.G.Z.)
| | - Mary Farrant
- Department of Neurology, University of California, San Francisco (J.D.E., M.F., A.S.K., K.G.Z.)
| | - William G Barsan
- Department of Emergency Medicine, University of Michigan, Ann Arbor (W.G.B.)
| | - Anthony S Kim
- Department of Neurology, University of California, San Francisco (J.D.E., M.F., A.S.K., K.G.Z.)
| | | | - Yuko Y Palesch
- Dean's Office, Dell Medical School, University of Texas, Austin (S.C.J.)
| | - Karla G Zurita
- Department of Neurology, University of California, San Francisco (J.D.E., M.F., A.S.K., K.G.Z.)
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, Palo Alto, CA (G.W.A., N.V.)
| | - Brett L Cucchiara
- Department of Neurology, University of Pennsylvania, Philadelphia (B.L.C.)
| | - Dawn O Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH (D.O.K.)
| | - Helmi L Lutsep
- Department of Neurology, Oregon Health and Science University, Portland (H.L.L.)
| | - Claire Pearson
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI (C.P.)
| | - Pramod Sethi
- Cone Health Comprehensive Stroke Center/Guilford Neurologic Associates, Greensboro, NC (P.S.)
| | - Nirali Vora
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, Palo Alto, CA (G.W.A., N.V.)
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Ye MB, Chen YL, Wang Q, An J, Ye F, Jing P. Aspirin plus clopidogrel versus aspirin mono-therapy for ischemic stroke: a meta-analysis. SCAND CARDIOVASC J 2019; 53:169-175. [PMID: 31112048 DOI: 10.1080/14017431.2019.1620962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives. Stroke is a common condition after a transient ischemic attack (TIA) or minor ischemic stroke (IS). Adding clopidogrel to aspirin may yield more beneficial outcomes than aspirin mono-therapy; meanwhile, the risk of bleeding in the acute phase remains poorly understood. Therefore, there is increasing emphasis on the risks and benefits of clopidogrel with aspirin compared with aspirin mono-therapy in an effort to treat TIA/IS. Design. We searched several electronic databases, including PubMed, Cochrane, and Embase, to identify eligible randomized controlled trials (RCTs) based on the index words comparing dual-antiplatelet therapy to aspirin mono-therapy for secondary stroke prevention updated to December, 2018. Results. A total of 11 RCTs met our inclusion criteria. The pooled analysis showed that clopidogrel plus aspirin was associated with a trend toward a reduction in recurrent IS (RR = 0.72, 95%CI = 0.65-0.81, p < .001), but not the recurrent stroke rate (RR = 0.81, 95% CI = 0.63-1.03, p = .09) than aspirin mono-therapy. There were differences in bleeding episodes (RR = 1.81, 95%CI = 1.65-1.99, p < .001), moderate-severe major bleeding (RR = 1.64, 95% CI = 1.24-2.16, p = .0005), or mild bleeding (RR = 2.25, 95%CI = 1.54-3.31, p < .001) between the study groups. Meanwhile, no benefit of reducing the risk of intracranial hemorrhage with dual-antiplatelet therapy was found in TIA/IS patients (RR = 1.44, 95% CI = 0.95-2.19, p = .09). Conclusions. The addition of clopidogrel to aspirin for patients with TIA or IS appeared to significantly reduce the risk of IS recurrence with a possible increase in the risk of bleeding compared with aspirin alone.
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Affiliation(s)
- Mao-Bin Ye
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Yan-Lin Chen
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Qin Wang
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Jun An
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Fei Ye
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Ping Jing
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
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Uchino K. Guideline: Starting dual antiplatelet therapy ≤ 24 h after high-risk TIA or minor ischemic stroke is recommended. Ann Intern Med 2019; 170:JC38. [PMID: 30986828 DOI: 10.7326/acpj201904160-038] [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: 11/22/2022] Open
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Rahman H, Khan SU, Nasir F, Hammad T, Meyer MA, Kaluski E. Optimal Duration of Aspirin Plus Clopidogrel After Ischemic Stroke or Transient Ischemic Attack. Stroke 2019; 50:947-953. [PMID: 30852971 PMCID: PMC7457746 DOI: 10.1161/strokeaha.118.023978] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/31/2019] [Indexed: 12/29/2022]
Abstract
Background and Purpose- The role of aspirin plus clopidogrel (A+C) therapy compared with aspirin monotherapy in patients presenting with acute ischemic stroke (IS) or transient ischemic attack remains uncertain. We conducted this study to determine the optimal period of efficacy and safety of A+C compared with aspirin monotherapy. Methods- Ten randomized controlled trials (15 434 patients) were selected using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) (inception June 2018) comparing A+C with aspirin monotherapy in patients with transient ischemic attack or IS. The primary efficacy outcome was recurrent IS, and the primary safety outcome was major bleeding. The secondary outcomes were major adverse cardiovascular events (composite of stroke, myocardial infarction, and cardiovascular mortality) and all-cause mortality. We stratified analysis based on the short- (≤1 month), intermediate- (≤3 month), and long-term (>3 month) A+C therapy. Effects were estimated as relative risk (RR) with 95% CI. Results- A+C significantly reduced the risk of recurrent IS at short-term (RR, 0.53; 95% CI, 0.37-0.78) and intermediate-term (RR, 0.72; 95% CI, 0.58-0.90) durations. Similarly, major adverse cardiovascular event was significantly reduced by short-term (RR, 0.68; 95% CI, 0.60-0.78) and intermediate-term (RR, 0.76; 95% CI, 0.61-0.94) A+C therapy. However, long-term A+C did not yield beneficial effect in terms of recurrent IS (RR, 0.81; 95% CI, 0.63-1.04) and major adverse cardiovascular events (RR, 0.87; 95% CI, 0.71-1.07). Intermediate-term (RR, 2.58; 95% CI, 1.19-5.60) and long-term (RR, 1.87; 95% CI, 1.36-2.56) A+C regimens significantly increased the risk of major bleeding as opposed to short-term A+C (RR, 1.82; 95% CI, 0.91-3.62). Excessive all-cause mortality was limited to long-term A+C (RR, 1.45; 95% CI, 1.10-1.93). Conclusions- Short-term A+C is more effective and equally safe in comparison to aspirin alone in patients with acute IS or transient ischemic attack.
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Affiliation(s)
- Hammad Rahman
- From the Department of Medicine (H.R., F.N., E.K.), Guthrie Health System/Robert Packer Hospital, Sayre, PA
| | - Safi U Khan
- Department of Medicine, West Virginia University, Morgantown (S.U.K.)
| | - Fahad Nasir
- From the Department of Medicine (H.R., F.N., E.K.), Guthrie Health System/Robert Packer Hospital, Sayre, PA
| | - Tehseen Hammad
- Department of Medicine, Services Hospital, Lahore, Pakistan (T.H.)
| | - Michael A Meyer
- Division of Neurology (M.A.M.), Guthrie Health System/Robert Packer Hospital, Sayre, PA
| | - Edo Kaluski
- From the Department of Medicine (H.R., F.N., E.K.), Guthrie Health System/Robert Packer Hospital, Sayre, PA
- Division of Cardiology, Rutgers New Jersey Medical School, Newark (E.K.)
- Division of Cardiology, The Geisinger Commonwealth Medical College, Scranton, PA (E.K.)
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Wang XH, Tao L, Zhou ZH, Li XQ, Chen HS. Antiplatelet vs. R-tPA for acute mild ischemic stroke: A prospective, random, and open label multi-center study. Int J Stroke 2019; 14:658-663. [PMID: 30907301 DOI: 10.1177/1747493019832998] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Rationale The evidence of intravenous thrombolysis in patients with not clearly disabling minor stroke (low National Institutes of Health Stroke Scale of 0–5) is still insufficient. Recent early terminated PRISMS trial could not provide definitive conclusion, although suggesting the similar functional outcome between alteplase and aspirin groups. Recent two clinical trials provide a definitive evidence for the superiority of dual antiplatelet to mono-antiplatelet in minor stroke. However, the efficacy and safety of dual antiplatelet vs. alteplase in the treatment of acute minor stroke are not known. Aim To explore the efficacy and safety of dual antiplatelet with aspirin and clopidogrel vs. alteplase in the treatment of acute minor stroke. Sample size estimates A maximum of 760 subjects are required to test the non-inferiority hypothesis with 80% power according to a one-sided 0.025 level of significance, stratified by age, diabetes, time from onset to treatment, stroke etiology, degree of vascular stenosis, location of index vessel. Methods and design ARAMIS is a prospective, randomized, open label, blinded assessment of endpoints (PROBE) and multicenter clinical trial in China. The subjects are randomized to the control arm (intravenous alteplase with standard dose of 0.9 mg/kg, followed by guideline-based treatment 24 h after thrombolysis) or the experiment arm (clopidogrel: loading dose of 300 mg on the first day, followed by 75 mg daily for 10–14 days; aspirin: 100 mg on the first day, followed by 100 mg daily for 10–14 days; after the combination, antiplatelet will be given based on guideline till 90 days). Study outcome The primary efficacy endpoint is favorable functional outcome, defined as a mRS 0–1 assessed at 90-day post-randomization.
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Affiliation(s)
- Xin-Hong Wang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Lin Tao
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Zhong-He Zhou
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Xiao-Qiu Li
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, P.R. China
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Hou X, Li X, Wang X, Chen H. Antiplatelet Therapy in Acute Mild-Moderate Ischemic Stroke (ATAMIS): a parallel, randomised, open-label, multicentre, prospective study. Stroke Vasc Neurol 2018; 3:263-267. [PMID: 30637134 PMCID: PMC6312068 DOI: 10.1136/svn-2018-000148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 07/30/2018] [Accepted: 08/31/2018] [Indexed: 01/01/2023] Open
Abstract
Background A recent study shows that dual antiplatelet therapy with clopidogrel plus aspirin is superior to aspirin monotherapy for minor stroke, which is defined as a National Institutes of Health Stroke Scale (NIHSS)score of ≤3. However, acute mild-moderate ischaemic stroke (4≤NIHSS≤10) still needs aggressive antiplatelet intervention to prevent deterioration and recurrence of stroke. The efficacy and safety of dual antiplatelet therapy versus aspirin monotherapy in the population are not clear. A multicentre clinical trial is designed to evaluate the efficacy and safety of clopidogrel plus aspirin therapy versus aspirin monotherapy within 48 hours of symptom onset of mild-moderate ischaemic stroke. Methods/Design The study is a randomised, open-label, multicentre, prospective trial with a target enrolment of 2700 patients from 60 centres in Northeast China. A treatment allocation identification number to each enrolled patient will be provided by a random number generator. The follow-up time for the clopidogrel plus aspirin and aspirin monotherapy groups is 90 days. The primary efficacy endpoint is a stroke progression event, which is defined as ≥4 point increase in the NIHSS score in 48 hours. The second efficacy endpoints include new ischaemic stroke within 90 days, change in the NIHSS score within 14 days, modified Rankin Scale score on day 90 and other vascular or death events within 90 days. The safety endpoints include mucocutaneous haemorrhage, organ haemorrhage and intracranial haemorrhage, adverse events and severe adverse events. χ2 test, t-test (or Mann-Whitney test), survival analysis and Cox proportional hazards models will be conducted. The findings of the study may provide an important evidence for clinical practice for these patients. Discussion The trial will be conducted under a rational design and will provide valuable evidence on the appropriate treatment for this population. Ethics and dissemination The study was reviewed and approved by the Ethics Committee of the General Hospital of Shen-Yang Military Region (no K(2016) 6). Trial registration number NCT02869009; Pre-results.
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Affiliation(s)
- Xiaowen Hou
- Department of Neurology, General Hospital of Shen-Yang Military Region, Shenyang, China
| | - Xiaoqiu Li
- Department of Neurology, General Hospital of Shen-Yang Military Region, Shenyang, China
| | - Xinhong Wang
- Department of Neurology, General Hospital of Shen-Yang Military Region, Shenyang, China
| | - Huisheng Chen
- Department of Neurology, General Hospital of Shen-Yang Military Region, Shenyang, China
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37
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Ding L, Peng B. Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a systematic review and meta‐analysis. Eur J Neurol 2018; 25:1276-1284. [PMID: 29855121 DOI: 10.1111/ene.13695] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 05/23/2018] [Indexed: 11/30/2022]
Affiliation(s)
- L. Ding
- Department of Neurology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
| | - B. Peng
- Department of Neurology Peking Union Medical College Hospital Chinese Academy of Medical Sciences Peking Union Medical College Beijing China
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Yang Y, Zhou M, Zhong X, Wang Y, Zhao X, Liu L, Wang Y. Dual versus mono antiplatelet therapy for acute non-cardioembolic ischaemic stroke or transient ischaemic attack: a systematic review and meta-analysis. Stroke Vasc Neurol 2018; 3:107-116. [PMID: 30022798 PMCID: PMC6047341 DOI: 10.1136/svn-2018-000168] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 05/31/2018] [Indexed: 12/18/2022] Open
Abstract
Objective Recent years have seen new evidence on the efficacy and safety of dual antiplatelet therapy for secondary stroke prevention. We updated a meta-analysis of randomised controlled trials evaluating dual antiplatelet versus monotherapy for patients with acute non-cardioembolic ischaemic stroke (IS) or transient ischaemic attack (TIA). Methods We searched PubMed and identified randomised controlled trials evaluating dual antiplatelet versus monotherapy for acute non-cardioembolic IS or TIA within 3 days of ictus up to May 2018. Risk ratio (RR) with 95% CI were calculated using random effects models. Clinical endpoints included stroke recurrence, composite vascular events and major bleeding. Results 18 randomised controlled trials including 15 515 patients were pooled in the meta-analysis. When compared with monotherapy among patients with acute IS or TIA, dual antiplatelet therapy reduced the risk of stroke recurrence (RR 0.69; 95% CI 0.61 to 0.78; p<0.001) and composite vascular events (RR 0.72; 95% CI 0.64 to 0.80; p<0.001). Dual therapy was associated with a significant increase in the risk of major bleeding (RR 1.77; 95% CI 1.09 to 2.87; p=0.02) when all trial data were combined. However, when all previous trials before the completion of the POINT trial were analysed, dual antiplatelet versus monotherapy was not associated with a significant increase in the risk of major bleeding (RR 1.46; 95% CI 0.77 to 2.75; p=0.25). Conclusions Among patients with acute non-cardioembolic IS or TIA within 3 days of ictus, dual antiplatelet therapy was associated with a reduction in stroke recurrence, and composite vascular events, when compared with monotherapy. However, a significant increase in the risk of major bleeding was observed.
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Affiliation(s)
- Yingying Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Mengyuan Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xi Zhong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
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Antiplatelet therapy after stroke: should it differ in the acute and chronic phase after stroke. Curr Opin Neurol 2018; 31:14-22. [PMID: 29084062 DOI: 10.1097/wco.0000000000000509] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Reviewing existing evidence regarding well tolerated and effective antiplatelet treatment in patients with acute or chronic, noncardioembolic ischemic stroke and transient ischemic attack (TIA). RECENT FINDINGS For patients with high-risk stroke or TIA, for instance, minor stroke or high-risk TIA, or stroke of atherosclerotic origin with evidence suggesting risk of artery-to-artery embolism or with high-grade, symptomatic arterial stenosis, early initiated, short-term dual antiplatelet (e.g. aspirin and clopidogrel) is effective in reducing the risk of recurrent stroke and other vascular events which does not increase the risk of severe or fatal bleeding, as compared with mono antiplatelet therapy. However, long-term application of aggressive antiplatelet therapies after a noncardioembolic stroke or TIA increases the bleeding risks. Triple antiplatelet therapy is not appropriate for noncardioembolic stroke or TIA, in view of the high bleeding risk. In addition, emerging antiplatelets such as ticagrelor and cilostazol may work better in certain subgroups of stroke patients, which warrants further investigation. SUMMARY Antiplatelet therapies should differ in the acute and chronic phases among patients with high-risk stroke or TIA when more aggressive antiplatelet treatment is reasonable in the acute phase, but no solid evidence supports different antiplatelet strategies in acute and chronic phases in patients with low-risk noncardioembolic stroke.
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Geisler T, Mengel A, Ziemann U, Poli S. Management of Embolic Stroke of Undetermined Source (ESUS). Drugs 2018; 78:823-831. [DOI: 10.1007/s40265-018-0912-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Walker J, Hutchison P, Ge J, Zhao D, Wang Y, Rothwell PM, Gaziano JM, Chan A, Burn J, Chia J, Langley R, O'Donnell V, Rocca B, Hawkey C. Aspirin: 120 years of innovation. A report from the 2017 Scientific Conference of the International Aspirin Foundation, 14 September 2017, Charité, Berlin. Ecancermedicalscience 2018; 12:813. [PMID: 29515654 PMCID: PMC5834311 DOI: 10.3332/ecancer.2018.813] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Indexed: 12/15/2022] Open
Abstract
Acetylsalicylic acid was first synthesised by Dr FeIix Hoffman on 10th August 1897 and Aspirin was born. It quickly became the best-known pain killer in the world and in the 120 years since this event, aspirin has continued to attract interest, innovation and excitement. Set within the walls of the preserved ruins of Rudolf Virchow's lecture hall at Charité, within Berlin's Museum of Medical History, the International Aspirin Foundation's 28th Scientific Conference served to facilitate international, multi-disease, multidisciplinary discussion about the current understanding of aspirin's mechanisms of action and its utility in modern medicine as well as ideas for future research into its multifaceted applications to enhance global health. In addition to the delegates in Berlin, 300 medical doctors at the 19th Annual Scientific Congress of the Chinese Society of Cardiology were able to join the cardiology sessions from Taiyuan, Shangxi province via a live streaming link to and from China. This led to useful discussion and allowed a truly international perspective to the meeting.
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Affiliation(s)
- Jaqui Walker
- International Aspirin Foundation, 34 Bower Mount Road, Maidstone, Kent ME16 8AU, UK
| | - Pippa Hutchison
- International Aspirin Foundation, 34 Bower Mount Road, Maidstone, Kent ME16 8AU, UK
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Disease, 180 Fenglin Rd, Xuhui Qu, Shanghai Shi, China
- Center for Stem Cells and Tissue Engineering, Fudan University, 220 Handan Rd, WuJiaoChang, Yangpu Qu, Shanghai Shi, 200433, China
| | - Dong Zhao
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
- Epidemiology Research Department, An Zhen Hospital, Beijing, China
| | - Yongjun Wang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Peter M Rothwell
- Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - J Michael Gaziano
- Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC), 150 South Huntington Avenue, Jamaica Plain, MA 02130, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Andrew Chan
- Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - John Burn
- Institute of Genetic Medicine, International Centre for Life, Times Square, Newcastle upon Tyne, NE1 3BZ, UK
| | - John Chia
- Department of Medical Oncology, National Cancer Centre, Bukit Merah, Singapore
| | - Ruth Langley
- Brighton and Sussex University Hospitals, UK
- Medical Research Council Clinical Trials Unit, University College London, 90 High Holborn, London WC1V 6LJ, UK
| | - Valerie O'Donnell
- Systems Immunity Research Institute, Cardiff University, Tenovus Building, Cardiff, CF14 4XN, UK
| | - Bianca Rocca
- Catholic University School of Medicine, Rome, Italy
| | - Chris Hawkey
- Faculty of Medicine and Health Sciences, University of Nottingham, Medical School, Queen's Medical Centre, Nottingham, NG7 2UH, UK
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Squizzato A, Bellesini M, Takeda A, Middeldorp S, Donadini MP. Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular events. Cochrane Database Syst Rev 2017; 12:CD005158. [PMID: 29240976 PMCID: PMC6486024 DOI: 10.1002/14651858.cd005158.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Aspirin is the prophylactic antiplatelet drug of choice for people with cardiovascular disease. Adding a second antiplatelet drug to aspirin may produce additional benefit for people at high risk and people with established cardiovascular disease. This is an update to a previously published review from 2011. OBJECTIVES To review the benefit and harm of adding clopidogrel to aspirin therapy for preventing cardiovascular events in people who have coronary disease, ischaemic cerebrovascular disease, peripheral arterial disease, or were at high risk of atherothrombotic disease, but did not have a coronary stent. SEARCH METHODS We updated the searches of CENTRAL (2017, Issue 6), MEDLINE (Ovid, 1946 to 4 July 2017) and Embase (Ovid, 1947 to 3 July 2017) on 4 July 2017. We also searched ClinicalTrials.gov and the WHO ICTRP portal, and handsearched reference lists. We applied no language restrictions. SELECTION CRITERIA We included all randomised controlled trials comparing over 30 days use of aspirin plus clopidogrel with aspirin plus placebo or aspirin alone in people with coronary disease, ischaemic cerebrovascular disease, peripheral arterial disease, or at high risk of atherothrombotic disease. We excluded studies including only people with coronary drug-eluting stent (DES) or non-DES, or both. DATA COLLECTION AND ANALYSIS We collected data on mortality from cardiovascular causes, all-cause mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal ischaemic stroke, major and minor bleeding. The overall treatment effect was estimated by the pooled risk ratio (RR) with 95% confidence interval (CI), using a fixed-effect model (Mantel-Haenszel); we used a random-effects model in cases of moderate or severe heterogeneity (I2 ≥ 30%). We assessed the quality of the evidence using the GRADE approach. We used GRADE profiler (GRADE Pro) to import data from Review Manager to create a 'Summary of findings' table. MAIN RESULTS The search identified 13 studies in addition to the two studies in the previous version of our systematic review. Overall, we included data from 15 trials with 33,970 people. We completed a 'Risk of bias' assessment for all studies. The risk of bias was low in four trials because they were at low risk of bias for all key domains (random sequence generation, allocation concealment, blinding, selective outcome reporting and incomplete outcome data), even if some of them were funded by the pharmaceutical industry.Analysis showed no difference in the effectiveness of aspirin plus clopidogrel in preventing cardiovascular mortality (RR 0.98, 95% CI 0.88 to 1.10; participants = 31,903; studies = 7; moderate quality evidence), and no evidence of a difference in all-cause mortality (RR 1.05, 95% CI 0.87 to 1.25; participants = 32,908; studies = 9; low quality evidence).There was a lower risk of fatal and non-fatal myocardial infarction with clopidogrel plus aspirin compared with aspirin plus placebo or aspirin alone (RR 0.78, 95% CI 0.69 to 0.90; participants = 16,175; studies = 6; moderate quality evidence). There was a reduction in the risk of fatal and non-fatal ischaemic stroke (RR 0.73, 95% CI 0.59 to 0.91; participants = 4006; studies = 5; moderate quality evidence).However, there was a higher risk of major bleeding with clopidogrel plus aspirin compared with aspirin plus placebo or aspirin alone (RR 1.44, 95% CI 1.25 to 1.64; participants = 33,300; studies = 10; moderate quality evidence) and of minor bleeding (RR 2.03, 95% CI 1.75 to 2.36; participants = 14,731; studies = 8; moderate quality evidence).Overall, we would expect 13 myocardial infarctions and 23 ischaemic strokes be prevented for every 1000 patients treated with the combination in a median follow-up period of 12 months, but 9 major bleeds and 33 minor bleeds would be caused during a median follow-up period of 10.5 and 6 months, respectively. AUTHORS' CONCLUSIONS The available evidence demonstrates that the use of clopidogrel plus aspirin in people at high risk of cardiovascular disease and people with established cardiovascular disease without a coronary stent is associated with a reduction in the risk of myocardial infarction and ischaemic stroke, and an increased risk of major and minor bleeding compared with aspirin alone. According to GRADE criteria, the quality of evidence was moderate for all outcomes except all-cause mortality (low quality evidence) and adverse events (very low quality evidence).
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Affiliation(s)
- Alessandro Squizzato
- University of InsubriaResearch Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Medicine and Surgery, School of Medicinec/o Medicina 1, ASST Settelaghi Ospedale di Circoloviale Borri, 57VareseItaly21100
| | - Marta Bellesini
- University of InsubriaResearch Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, School of MedicineVareseItaly
| | - Andrea Takeda
- University College LondonFarr Institute of Health Informatics ResearchLondonUK
| | - Saskia Middeldorp
- Academic Medical CenterDepartment of Vascular MedicineMeibergdreef 9AmsterdamNetherlands1105AZ
| | - Marco Paolo Donadini
- University of InsubriaResearch Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, School of MedicineVareseItaly
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Pan Y, Wang Y, Wang Y. Author response: Risks and benefits of clopidogrel-aspirin in minor stroke or TIA: Time course analysis of CHANCE. Neurology 2017; 89:2121-2122. [PMID: 29133611 DOI: 10.1212/wnl.0000000000004655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Lemmens R, Al-Shahi Salman R. Individualized risk prediction of major bleeding in secondary stroke prevention: Are we there yet? Neurology 2017; 89:882-883. [PMID: 28768843 DOI: 10.1212/wnl.0000000000004303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Robin Lemmens
- From the Department of Neurosciences (R.L.), Experimental Neurology and Leuven Institute for Neuroscience and Disease (LIND), KU Leuven-University of Leuven; Laboratory of Neurobiology (R.L.), Center for Brain & Disease Research, VIB, Leuven; Department of Neurology (R.L.), University Hospitals Leuven, Belgium; and Centre for Clinical Brain Sciences (R.A.S.), University of Edinburgh, UK.
| | - Rustam Al-Shahi Salman
- From the Department of Neurosciences (R.L.), Experimental Neurology and Leuven Institute for Neuroscience and Disease (LIND), KU Leuven-University of Leuven; Laboratory of Neurobiology (R.L.), Center for Brain & Disease Research, VIB, Leuven; Department of Neurology (R.L.), University Hospitals Leuven, Belgium; and Centre for Clinical Brain Sciences (R.A.S.), University of Edinburgh, UK
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