The Efficacy and Safety of 3 Types of Interventions for Stroke Prevention in Patients With Cardiovascular and Cerebrovascular Diseases: A Network Meta-analysis

Abstract

PurposeThe goal of this study was to compare the relative efficacy and safety of different types of interventions for stroke prevention in patients with cardiovascular and cerebrovascular diseases. MethodsThis network meta-analysis (NMA) was conducted with a random effects model of Bayesian framework using Stata version 12.0. Odds ratios (ORs) and their credible intervals (CrIs) were applied for the efficacy and safety evaluation of various medical interventions, including aspirin, dipyridamole, ticlopidine, warfarin, and apixaban. In addition, the ranking of probability of every clinical outcome was estimated by comparing the surface under the cumulative ranking curve. FindingsCompared with dabigatran, both edoxaban and aspirin + warfarin exhibited a higher rate of all-cause stroke (OR, 2.84 [95% CrI, 1.17–6.97]; OR, 3.42 [95% CrI, 1.20–9.84]). With respect to intracranial hemorrhage, aspirin + clopidogrel yielded worse outcomes than 7 treatments, including placebo, apixaban, aspirin, aspirin + dipyridamole, cilostazol, clopidogrel, and dabigatran (OR, 2.21 [95% CrI, 1.45–3.40]; OR, 2.11 [95% CrI, 1.05–4.17]; OR, 1.53 [95% CrI, 1.11–2.15]; OR, 1.78 [95% CrI, 1.01–3.03]; OR, 4.17 [95% CrI, 1.37–14.28]; OR, 1.85 [95% CrI, 1.22–2.86]; and OR, 2.56 [95% CrI, 1.37–4.76]). In terms of ischemic stroke, dabigatran provided better efficacy than placebo, aspirin, and aspirin + dipyridamole (OR, 0.36 [95% CrI, 0.18–0.72]; OR, 0.43 [95% CrI, 0.21–0.84]; and OR, 0.41 [95% CrI, 0.17–0.94]). As for mortality, dabigatran resulted in a lower mortality compared with aspirin, aspirin + clopidogrel, edoxaban, and warfarin (OR, 0.48 [95% CrI, 0.23–0.97]; OR, 0.40 [95% CrI, 0.17–0.92]; OR, 0.27 [95% CrI, 0.10–0.72]; and OR, 0.52 [95% CrI, 0.28–0.92]). ImplicationsThere are still some limitations to our NMA research. For instance, the lack of direct evidence for some therapies resulted in inconsistencies, particularly for warfarin compared with placebo and clopidogrel under different end points. Moreover, the included randomized controlled trials for patients with cardiovascular and cerebrovascular diseases are relatively broad, involving atrial fibrillation, myocardial infarction, and large-artery atherosclerosis stroke. Although further research is needed, dabigatran is highly recommended based on the present NAM for the treatment of cardiovascular and cerebrovascular diseases due to the drug’s efficacy and safety.