scholarly journals Benefits and Risks of Clopidogrel vs. Aspirin Monotherapy after Recent Ischemic Stroke: A Systematic Review and Meta-Analysis

2019 ◽  
Vol 2019 ◽  
pp. 1-12 ◽  
Author(s):  
Maurizio Paciaroni ◽  
Birsen Ince ◽  
Bo Hu ◽  
Jiann-Shing Jeng ◽  
Kursad Kutluk ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Secondary Prevention ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
Significant Risk ◽  
Limited Data ◽  
Bleeding Events ◽  
Eligibility Criteria ◽  
Cerebrovascular Events ◽  
Ischemic Attack

Aim. Though combination of clopidogrel added to aspirin has been compared to aspirin alone in patients with stroke or transient ischemic attack, limited data exists on the relative efficacy and safety between clopidogrel and aspirin monotherapy in patients with a recent ischemic stroke. We aimed to compare clopidogrel versus aspirin monotherapy in this population. Methods. PubMed, Embase, and CENTRAL databases were searched from inception to May 2018 to identify clinical trials and observational studies comparing clopidogrel versus aspirin for secondary prevention in patients with recent ischemic stroke within 12 months. Pooled effect estimates were calculated using a random effects model and were reported as risk ratios with 95% confidence intervals. Results. Five studies meeting eligibility criteria were included in the analysis. A total of 29,357 adult patients who had recent ischemic stroke received either clopidogrel (n=14,293) or aspirin (n=15,064) for secondary prevention. Pairwise meta-analysis showed a statistically significant risk reduction in the occurrence of major adverse cardiovascular and cerebrovascular events (risk ratio 0.72 [95% CI, 0.53–0.97]), any ischemic or hemorrhagic stroke (0.76 [0.58, 0.99), and recurrent ischemic stroke (0.72 [0.55, 0.94]) in patients who received clopidogrel versus aspirin. The risk of bleeding was also lower for clopidogrel versus aspirin (0.57 [0.45, 0.74]). There was no difference in the rate of all-cause mortality between the two groups. Conclusions. The analysis showed lower risks of major adverse cardiovascular or cerebrovascular events, recurrent stroke, and bleeding events for clopidogrel monotherapy compared to aspirin. These findings support clinical benefit for single antiplatelet therapy with clopidogrel over aspirin for secondary prevention in patients with recent ischemic stroke.

2014 Chinese guidelines for secondary prevention of ischemic stroke and transient ischemic attack

2017 ◽  
Vol 12 (3) ◽  
pp. 302-320 ◽  
Author(s):  
Yongjun Wang ◽  
Ming Liu ◽  
Chuanqiang Pu
Keyword(s):  
Ischemic Stroke ◽  
Secondary Prevention ◽  
Transient Ischemic Attack ◽  
Recurrent Stroke ◽  
Stroke Recurrence ◽  
Evidence Based ◽  
Cerebrovascular Disorder ◽  
Level Of Evidence ◽  
Vascular Stenosis ◽  
Ischemic Attack

Ischemic stroke and transient ischemic attack (TIA) are the most common cerebrovascular disorder and leading cause of death in China. The Effective secondary prevention is the vital strategy for reducing stroke recurrence. The aim of this guideline is to provide the most updated evidence-based recommendation to clinical physicians from the prior version. Control of risk factors, intervention for vascular stenosis/occlusion, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke are all recommended, and the prevention of recurrent stroke in a variety of uncommon causes and subtype provided as well. We modified the level of evidence and recommendation according to part of results from domestic RCT in order to facility the clinical practice.

Abstract WP370: Cerebral Microbleeds Play an Important Role in Turning Recurrent Stroke Towards Intracranial Hemorrhage in Patients With First-ever Ischemic Stroke/Transient Ischemic Attack

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Eiichi Nomura ◽  
Yuji Shiga ◽  
Shinichi Takeshima ◽  
Makoto Takemaru ◽  
Jun Takeshita ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Transient Ischemic Attack ◽  
Recurrent Stroke ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Cerebral Microbleeds ◽  
Antithrombotic Agent ◽  
Ischemic Attack ◽  
First Admission

Background and Purpose: After ischemic stroke (IS) or transient ischemic attack (TIA), use of an antithrombotic agent to prevent recurrence is mandatory. However, antithrombotic agents rarely cause intracranial hemorrhage (ICH), frequently resulting in worse outcomes than recurrent IS. Cerebral microbleeds (CMBs) have been reported as a useful marker for finding ICH-prone patients. This retrospective study aimed to investigate the significance of CMB in the development of ICH in first-ever IS/TIA patients. Methods: The data source was our consecutive patient registry between 2005 and 2015. Patients with stroke/TIA admitted to our hospital more than twice (first as first-ever IS/TIA and second or later as recurrent IS/TIA or ICH) and underwent head MRI including T2*-weighted imaging on the first admission were extracted. Clinical characteristics including use of antithrombotic therapy and distribution of CMB on the first and second admissions were compared between recurrent IS/TIA and ICH groups. Distribution of CMB was divided into deep, lobar, or both. Results: In total, 708 IS/TIA patients (second stroke: 640 IS/TIA; 68 ICH) were extracted. The ICH group showed a longer period until second stroke (1,062 days vs. 817 days, p=0.022) and higher mean NIHSS score (14.8 vs. 6.1, p<0.001) on second admission than the IS/TIA group. On first admission, the ICH group had a higher frequency of CMB (72.1% vs. 49.5%, p<0.001) and lower frequency of cardioembolism (14.7% vs. 25.8%, p=0.044) than the IS/TIA group. About half of hemorrhages occurred in similar locations of the CMB depicted on first admission. A higher frequency of ICH was observed in patients with deep CMB (11.3% vs. 5.6%, p=0.022) or both deep and lobar CMBs (17.4% vs. 5.6%, p<0.001) than in those without CMB. Use of anticoagulants was a significant risk factor for transition from first IS/TIA to second ICH (odds ratio [95% confidence interval]: 3.75 [1.30-10.8], adjusted by sex, age, type of first stroke, and CMB location). Conclusions: This study found IS/TIA patients with CMB are at high risk of ICH compared to patients without CMB. Preventive antithrombotic treatment particularly use of anticoagulants for CI/TIA patients with CMB should be provided under careful monitoring for the risk of hemorrhage.

scholarly journals Ischemic Stroke Patients Demonstrate Increased Carotid Plaque Microvasculature Compared to (Ocular) Transient Ischemic Attack Patients

2017 ◽  
Vol 44 (5-6) ◽  
pp. 297-303 ◽  
Author(s):  
Raf H.M. van Hoof ◽  
Floris H.B.M. Schreuder ◽  
Patty Nelemans ◽  
Martine T.B. Truijman ◽  
Narender P. van Orshoven ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Transient Ischemic Attack ◽  
Recurrent Stroke ◽  
Clinical Risk Factors ◽  
Dce Mri ◽  
Clinical Risk ◽  
Cerebrovascular Events ◽  
Ischemic Attack ◽  
Prospective Longitudinal

Background: Patients with a recent ischemic stroke have a higher risk of recurrent stroke compared to (ocular) transient ischemic attack (TIA) patients. Plaque microvasculature is considered as a feature of plaque vulnerability and can be quantified with carotid dynamic contrast-enhanced MRI (DCE-MRI). The purpose of this cross-sectional study was to explore the association between plaque microvasculature and the type of recent cerebrovascular events in symptomatic patients with mild-to-moderate carotid stenosis. Methods: A total of 87 symptomatic patients with a recent stroke (n = 35) or (ocular) TIA (n = 52) underwent carotid DCE-MRI examination. Plaque microvasculature was studied in the vessel wall and adventitia using DCE-MRI and the pharmacokinetic modeling parameter Ktrans. Statistical analysis was performed with logistic regression, correcting for associated clinical risk factors. Results: The 75th percentile adventitial (OR 1.97, 95% CI 1.18-3.29) Ktrans was significantly associated with a recent ischemic stroke compared to (ocular) TIA in multivariate analysis, while clinical risk factors were not significantly associated with the type of event. Conclusions: This study indicates a positive association of leaky plaque microvasculature with a recent ischemic stroke compared to (ocular) TIA. Prospective longitudinal studies are needed to investigate whether Ktrans or other plaque characteristics may serve as an imaging marker for predicting (the type of) future cerebrovascular events.

scholarly journals P.072 Ticagrelor vs Clopidogrel in Addition to Aspirin in Minor Ischemic Stroke/ TIA – a Systematic Review & Network Meta-Analysis (NMA)

2021 ◽  
Vol 48 (s3) ◽  
pp. S39-S39
Author(s):  
R Lun ◽  
S Dhaliwal ◽  
G Zitikyte ◽  
D Roy ◽  
B Hutton ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
Minor Stroke ◽  
Individual Outcomes ◽  
Minor Ischemic Stroke ◽  
Efficacy Outcome ◽  
Significant Difference ◽  
Credible Intervals ◽  
Ischemic Attack

Background: Dual antiplatelet therapy (DAPT) is recommended after minor ischemic stroke/ transient ischemic attack (TIA), but Clopidogrel/ Aspirin has never been compared directly to Ticagrelor/ Aspirin. Our objective is to compare these regimens in terms of efficacy and safety. Methods: Medline, Embase, and Cochrane were searched for randomized controlled trials (RCTs) that enrolled adults with minor stroke/ TIA and administered antiplatelets within 72 hours. The primary efficacy outcome is recurrent stroke or death at 90 days. We performed a Bayesian-approach NMA. Between group comparisons were presented as odds-ratios (OR) with 95% credible intervals (95%CI). Sucraplots were based on calculated probabilities of rankings for individual outcomes. Results: 9/4014 studies were included: 5 RCTs and 4 subgroup analyses. 22,098 patients were analyzed. At 90 days, both DAPT regimens were superior to Aspirin in the prevention of recurrent stroke/ death. There was no significant difference between Clopidogrel/ ASA compared to Ticagrelor/ ASA (OR 0.90 [95%CI 0.74 – 1.09]), although Clopidogrel/ Aspirin was ranked #1 using Sucraplots. There was no significant difference between the interventions for mortality, bleeding, or adverse events. Conclusions: DAPT was superior to ASA in the prevention of recurrent strokes/ death, but there was no difference between Clopidogrel/ ASA and Ticagrelor/ ASA.

scholarly journals Effectiveness of Platelet Function Analysis-Guided Aspirin and/or Clopidogrel Therapy in Preventing Secondary Stroke: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 9 (12) ◽  
pp. 3907
Author(s):  
Ann-Rong Yan ◽  
Mark Naunton ◽  
Gregory M. Peterson ◽  
Israel Fernandez-Cadenas ◽  
Reza Mortazavi
Keyword(s):  
Antiplatelet Therapy ◽  
Platelet Function ◽  
Patient Adherence ◽  
Function Analysis ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Bleeding Events ◽  
Recurrent Strokes ◽  
Ischemic Attack

Background: Antiplatelet medications such as aspirin and clopidogrel are used following thrombotic stroke or transient ischemic attack (TIA) to prevent a recurrent stroke. However, the antiplatelet treatments fail frequently, and patients experience recurrent stroke. One approach to lower the rates of recurrence may be the individualized antiplatelet therapies (antiplatelet therapy modification (ATM)) based on the results of platelet function analysis (PFA). This review was undertaken to gather and analyze the evidence about the effectiveness of such approaches. Methods: We searched Medline, CINAHL, Embase, Web of Science, and Cochrane databases up to 7 January 2020. Results: Two observational studies involving 1136 patients were included. The overall effects of PFA-based ATM on recurrent strokes (odds ratio (OR) 1.05; 95% confidence interval (CI) 0.69 to 1.58), any bleeding risk (OR 1.39; 95% CI 0.92 to 2.10) or death hazard from any cause (OR 1.19; 95% CI 0.62 to 2.29) were not significantly different from the standard antiplatelet therapy without ATM. Conclusions: The two studies showed opposite effects of PFA-guided ATM on the recurrent strokes in aspirin non-responders, leading to an insignificant difference in the subgroup meta-analysis (OR 1.59; 95% CI 0.07 to 33.77), while the rates of any bleeding events (OR 1.04; 95% CI 0.49 to 2.17) or death from any cause (OR 1.17; 95% CI 0.41 to 3.35) were not significantly different between aspirin non-responders with ATM and those without ATM. There is a need for large, randomized controlled trials which account for potential confounders such as ischemic stroke subtypes, technical variations in the testing protocols, patient adherence to therapy and pharmacogenetic differences.

Abstract P1: Antiplatelet Therapy for Secondary Prevention After Ischemic Stroke: Systematic Review and a Network Meta-Analysis From Randomized Trials

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Takahisa Mikami ◽  
Michika Sakamoto ◽  
Toshiki Kuno ◽  
Akira Machida ◽  
Evan Siau ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Combination Therapy ◽  
Secondary Prevention ◽  
Major Bleeding ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
Antiplatelet Agents ◽  
Similar Efficacy ◽  
Significant Heterogeneity ◽  
Significant Difference

Introduction: While various antiplatelet regimens are currently available for secondary prevention after ischemic stroke, data comparing their efficacy and safety are scarce. We conducted a network meta-analysis investigating the efficacy and risk profile of each antiplatelet regimen including combination therapies for secondary prevention of recurrent stroke. Methods: PubMed and EMBASE were searched for reports on randomized controlled trials published between January 1, 1985, and July 21, 2020. Random-effects model was used for meta-analysis. Primary outcome was recurrent stroke after ischemic stroke and secondary outcomes was major bleeding. Results: 39 trials enrolling a total of 158,507 patients were eligible for our network meta-analysis. Patients were randomly allocated to receive aspirin, cilostazol, clopidogrel, dipyridamole, ticagrelor, ticlopidine, or combination of these antiplatelet agents in each study. In comparison to those who received aspirin monotherapy, the risk of recurrent stroke was significantly lower in patients who received cilostazol (odds ratio (OR), 0.65; 95% confidence interval (CI), 0.51-0.83), aspirin + ticagrelor (OR, 0.72; 95% CI, 0.62-0.83), aspirin + clopidogrel (OR, 0.73; 95% CI, 0.54-0.98) without significant heterogeneity (I2=45.1). Ticagrelor monotherapy did not demonstrate a significant difference in risk of recurrent stroke compared to clopidogrel monotherapy (OR, 1.02; 95% CI, 0.70-1.48). Aspirin and ticagrelor combination therapy did not demonstrate a significant difference in risk of recurrent stroke compared to aspirin and clopidogrel combination therapy (OR, 1.01; 95% CI, 0.74-1.39). Combination therapy of aspirin with clopidogrel or ticagrelor showed a higher risk of major bleeding compared to aspirin monotherapy (OR, 1.54; 95% CI, 1.30-1.84; OR, 2.93; 95% CI, 1.53-5.41, respectively). Conclusions: Ticagrelor and clopidogrel demonstrated similar efficacy and risk of major bleeding—as monotherapy and in combination with aspirin—when used for secondary prevention of recurrent stroke. Ticagrelor or clopidogrel in combination with aspirin showed lower risk of recurrent stroke but higher risk of major bleeding than aspirin monotherapy.

scholarly journals Ticagrelor vs Clopidogrel in addition to Aspirin in minor ischemic stroke/ transient ischemic attack—Protocol for a systematic review and network meta-analysis

PLoS ONE ◽  
2021 ◽  
Vol 16 (4) ◽  
pp. e0250553
Author(s):  
Gabriele Zitikyte ◽  
Danielle Carole Roy ◽  
Shan Dhaliwal ◽  
Ronda Lun ◽  
Brian Hutton ◽  
...  
Keyword(s):  
Systematic Review ◽  
Ischemic Stroke ◽  
High Risk ◽  
Transient Ischemic Attack ◽  
Symptom Onset ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
Controlled Trials ◽  
Minor Ischemic Stroke ◽  
Ischemic Attack

Introduction Patients with minor ischemic stroke or transient ischemic attack represent a high-risk population for recurrent stroke. No direct comparison exists comparing dual antiplatelet therapy regimens—namely, Ticagrelor and Aspirin versus Clopidogrel and Aspirin. This systematic review and network meta-analysis (NMA) will examine the efficacy of these two different antiplatelet regimens in preventing recurrent stroke and mortality up to 30 days. Methods and analysis MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) will be searched with the assistance of a medical information specialist. Two independent reviewers will screen studies for inclusion; eligible studies will include randomized controlled trials that enrolled adults presenting with acute minor ischemic stroke or transient ischemic attack and compared one or more of the interventions against each other and/or a control. The primary outcomes will be recurrent ischemic stroke up to 30 days from symptom onset. Secondary outcomes will include safety outcomes (I.e. major bleeding and mortality), functional disability, and outcomes up to 90 days from symptom onset. A Bayesian approach to NMA will be implemented using the BUGSnet function in R Software. Between group comparisons for time-to-event (TTE) and dichotomous outcomes will be presented in terms of hazard ratios and odds ratios with 95% credible intervals, respectively. Secondary effect measures of treatment ranking will also be estimated. Ethics and dissemination No formal research ethics approval are necessary. We will disseminate our findings through scientific conference presentations, peer-reviewed publications, and social media/the press. The findings from this review will aid clinicians in decision-making on the choice of antithrombotic therapy in a high-risk stroke population and could be important in the development of future treatment trials and guidelines. Registration ID with Open Science Framework: 10.17605/OSF.IO/XDJYZ.

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