Abstract
BackgroundThe best antithrombotic strategy for cryptogenic stroke with potential cardiac emboli is not known. The objective of this study was to conduct a meta-analysis to evaluate the efficacy and safety of oral anticoagulants (OACs) vs. antiplatelet therapies in these patients MethodsPubmed, EMBASE, CENTRAL and clinicaltrials.gov were searched from January 1980 to April 2021 to identify trials comparing OACs versus antiplatelet therapies in patients with cryptogenic stroke and potential cardiac emboli (patent foramen ovale, moderate-severe left atrial enlargement, heart failure with reduced ejection fraction). Relative risk (RR) with 95% confidence (CI) was used as a measure of the effect of OACs versus antiplatelet therapies on recurrent ischemic stroke and major bleeding. We computed a random-effect estimate based on the Mantel-Haenszel method for a given outcome. ResultsWe identified 6 studies derived from 5 trials with 2282 patients. Pooled results from 6 studies showed that compared with antiplatelet therapies, OACs were associated with a lower risk of recurrent ischemic stroke (RR 0.61, 95% CI 0.41 to 0.91, P=0.02). Only 3 studies of cryptogenic stroke with patent foramen ovale reported a major bleeding endpoint and pooled results from random-effects model showed that OACs compared with antiplatelet therapies were associated with a non-significantly increased risk of major bleeding (RR 1.61, 95% CI 0.76 to 3.40, P=0.21). ConclusionsOACs compared with antiplatelet therapies were associated with a reduced recurrent ischemic stroke risk and OACs might be a viable non-procedural alternative in patients with cryptogenic stroke and potential cardiac emboli.
Highlights
Cryptogenic strokes are cerebral infarcts for which no probable un derlying pathophysiologic cause is identified after adequate diagnostic evaluation [1]
We included crypto genic stroke with patent foramen ovale (PFO) irrespective of grade and presence of atrial septal aneurysm/defect, with moderate or severe left atrial enlargement (LAE) defined as left atrial diameter > 4.6 cm, and with Heart failure with reduced ejec tion fraction (HFrEF) defined as heart failure with left ventricular ejection fraction 35% or less. (3) the study included a comparison of an oral anticoag ulants (OACs) with antiplatelet therapy; (4) recurrent ischemic stroke was reported as an endpoint; (5) total participants and the number with recurrent ischemic stroke were reported separately in each group; and (6) treatment duration was for at least 6 months
Additional exclusion criteria were if participants had (1) blood coagulation disorder; (2) an antiplatelet agent was used in an active arm; or (3) an OAC was used in a control arm
Summary
Cryptogenic strokes are cerebral infarcts for which no probable un derlying pathophysiologic cause is identified after adequate diagnostic evaluation [1]. The objective of this study was to conduct a meta-analysis to evaluate the efficacy and safety of oral anticoag ulants (OACs) vs antiplatelet therapies in these patients Methods: Pubmed, EMBASE, CENTRAL and clinicaltrials.gov were searched from January 1980 to April 2021 to identify trials comparing OACs versus antiplatelet therapies in patients with cryptogenic stroke and potential cardiac emboli (patent foramen ovale, moderate-severe left atrial enlargement, heart failure with reduced ejection fraction). 3 studies of cryptogenic stroke with patent foramen ovale reported a major bleeding endpoint and pooled results from random-effects model showed that OACs compared with antiplatelet therapies were associated with a non-significantly increased risk of major bleeding (RR 1.61, 95% CI 0.76 to 3.40, P=0.21). Conclusions: OACs compared with antiplatelet therapies were associated with a reduced recurrent ischemic stroke risk and OACs might be a viable non-procedural alternative in patients with cryptogenic stroke and potential cardiac emboli
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