Antiplatelet Therapy For Preventing Stroke Research Articles

Management and outcomes of cerebrovascular injuries after gunshot wounds to the cervical spine

Study designThis study was a multicenter retrospective analysis of cervical spine gunshot wound (GSW) patients. ObjectiveThe present study was conducted to evaluate the management and outcomes of vascular injuries following GSW involving the cervical spine. Summary of background dataGunshot wounds (GSW) injuring the cervical spine are associated with high rates of vascular injury. MethodsCharts of patients with GSW involving the cervical spine at two Level 1 trauma centers were reviewed from 2010 to 2021 for demographics, injury characteristics, management and follow-up. Statistical analysis included T tests and ANOVA for comparisons of continuous variables and chi-square testing for categorical variables, non-parametric tests were used when indicated. Beta-binomial models were used to estimate the probabilities outcomes. Bayesian regression models were utilized to compute risk ratios (RR) and their 95 % confidence intervals (CI) to enhance the inferential robustness. Results40 patients with cervical spine GSW and associated cerebrovascular injury were included in our analysis. 15 % of patients had Biffl grade (BG) V injuries, 50 % grade IV, and 35 % grade III–I. Angiography was performed in 35 % of patients. 5 of these patients (BG V–III) required endovascular treatment for pseudoaneurysm obliteration or parent vessel sacrifice. 7 patients (22 %) showed evidence of progression. 70 % of patients were placed on antiplatelet therapy for stroke prevention. Bayesian regression models with a skeptical prior for cerebral ischemia revealed a mean RR of 4.82 (95 % CI 1.02–14.48) in the BG V group, 0.75 (95 % CI 0.13–2.26) in the BG IV group, and 0.61 (95 % CI 0.06–2.01) in the combined BG III-I group. For demise the mean RR was 3.41 (95 % CI 0.58–10.65) in the BG V group and 1.69 (95 % CI 0.29–5.97) in the BG IV group. In the high BG (V, IV) group, 54.55 % of patients treated with antiplatelet therapy had complications. None of the patients that were treated with antiplatelet therapy in the low BG (III–I) group had complications. ConclusionsCervical spine GSWs are associated with high-grade vascular injuries and may require early endovascular intervention. Additionally, a high rate of injury progression was seen on follow up imaging, requiring subsequent intervention. Reintervention and demise were common and observed in high BG (V, IV) groups. The incidence of stroke was low, especially in low BG (I–III) groups, suggesting that daily aspirin prophylaxis is adequate for long-term stroke prevention.

Canadian Stroke Best Practice Recommendations: Acute Stroke Management, 7th Edition Practice Guidelines Update, 2022.

The 2022 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Acute Stroke Management, 7th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by an interdisciplinary team of healthcare providers and system planners caring for persons with an acute stroke or transient ischemic attack. These recommendations are a timely opportunity to reassess current processes to ensure efficient access to acute stroke diagnostics, treatments, and management strategies, proven to reduce mortality and morbidity. The topics covered include prehospital care, emergency department care, intravenous thrombolysis and endovascular thrombectomy (EVT), prevention and management of inhospital complications, vascular risk factor reduction, early rehabilitation, and end-of-life care. These recommendations pertain primarily to an acute ischemic vascular event. Notable changes in the 7th edition include recommendations pertaining the use of tenecteplase, thrombolysis as a bridging therapy prior to mechanical thrombectomy, dual antiplatelet therapy for stroke prevention, the management of symptomatic intracerebral hemorrhage following thrombolysis, acute stroke imaging, care of patients undergoing EVT, medical assistance in dying, and virtual stroke care. An explicit effort was made to address sex and gender differences wherever possible. The theme of the 7th edition of the CSBPR is building connections to optimize individual outcomes, recognizing that many people who present with acute stroke often also have multiple comorbid conditions, are medically more complex, and require a coordinated interdisciplinary approach for optimal recovery. Additional materials to support timely implementation and quality monitoring of these recommendations are available at www.strokebestpractices.ca.

Optimizing the Time Course of Risks and Benefits of Acute Dual Antiplatelet Therapy for Stroke Prevention

Optimizing the Time Course of Risks and Benefits of Acute Dual Antiplatelet Therapy for Stroke Prevention

Abstract 9424: Single versus Dual Antiplatelet Therapy for Stroke Prevention Following Left Atrial Appendage Occlusion in Patients With High Bleeding Risk

Introduction: The optimal antiplatelet therapy following Left atrial appendage occlusion (LAAO) in atrial fibrillation patients who are not candidates for long-term oral anticoagulation therapy (OAC) is subject to debate. Hypothesis: Is single antiplatelet therapy (SAPT) safe and effective when compared to dual antiplatelet therapy (DAPT) in patients with high bleeding risk? Methods: We conducted a comprehensive search for all studies that compared the use of SAPT with DAPT following LAAO for patients in whom OAC is deemed highly risky or contraindicated. The outcomes of our study were device-related thrombosis (DRT), stroke and systemic embolization (SSE), and major bleeding (MB). The risk ratio (RR) with 95% confidence intervals (CIs) are presented as summary statistics and were calculated using a random-effects model. Results: A total of 15 observational studies with 3231 patients (SAPT, n=1036; DAPT, n=2195; 64.5% men; median follow-up duration 12 months; mean age 74.7±8.5 years; CHA2DS2-VASc score 4.3±1.6; HASBLED score 3.2±1.2) were included. For DRT, data were available from 10 studies (2910 patients); there was no difference between SAPT and DAPT groups (2.6% vs. 2.3%; RR: 1.41; 95%CI: 0.77-2.59; P=0.26; I 2 :0%). For SSE (8 studies, 959 patients); although numerically more events were observed in the SAPT group, there was no statistical difference between the two groups in the pooled analysis (2.9% vs. 1.5%; RR: 5.43; 95%CI: 0.74-39.81; P=0.1; I 2 :78%). Finally, for MB (8 studies, 1818 patients); although numerically more events were observed in the DAPT group, there was no statistical difference between the two arms (2.3% vs. 3.2%; RR: 1.90; 95%CI: 0.46-7.87; P=0.37; I 2 :72%). Conclusions: Our study showed comparable safety and efficacy profiles for SAPT and DAPT after LAAO. Adequately powered randomized studies determining the optimal antithrombotic therapy in the first weeks after LAAO are warranted in patients at high risk for bleeding.

Total autogenous revascularization of an innominate artery occlusive disease

Total autogenous revascularization of an innominate artery occlusive disease

Antiplatelet Therapy in Cerebral Small Vessel Disease.

We critically evaluate the evidence for the use of antiplatelet therapy for stroke prevention following lacunar stroke and in patients with hemorrhage-prone cerebral small vessel disease. Pooled lacunar stroke subgroup analyses of all relevant randomized controlled trials to date suggest a 22% relative risk reduction in recurrent stroke by single antiplatelet therapy (RR 0.77, 95% CI 0.62-0.97) compared with placebo, no consistent suggestion of variable efficacy amongst specific antiplatelet agents, and the absence of clear benefit with dual over single antiplatelet therapy. Current data does not support withholding antiplatelet therapy where otherwise indicated in patients with cerebral microbleeds on MRI or those who have suffered intracerebral hemorrhage. Antiplatelet monotherapy appears to provide persistent secondary stroke prevention in patients with lacunar stroke. Whether phosphodiesterase inhibitors, particularly cilostazol, provide additional advantage in patients with cerebral small vessel disease is worthy of further investigation.

Non-Vitamin K Antagonist Oral Anticoagulants and Antiplatelet Therapy for Stroke Prevention in Patients With Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials.

Non-vitamin K antagonist oral anticoagulants (NOACs) are frequently used to prevent stroke in patients with atrial fibrillation. These patients are often also on aspirin or other antiplatelet agents. It is possible that treatment with both NOACs and aspirin or other antiplatelet drug may be effective in decreasing stroke, but data are sparse regarding the efficacy and safety of using both agents for stroke prevention. To address these issues, data were pooled from the 4 recent randomized, controlled trials of NOACs: apixaban, rivaroxaban, dabigatran, and edoxaban, which included 42,411 patients; 14,148 (33.4%) were also on aspirin or other antiplatelet drug. The number of thromboembolic events among participants on NOAC and aspirin/antiplatelet was compared with the number of events in patients on NOAC alone. Bleeding rates were also compared between those on NOAC + aspirin/antiplatelet and on NOAC alone. These results were compared with thromboembolic and bleeding events in the warfarin + aspirin/antiplatelet versus warfarin alone. No greater risk for thromboembolism was seen in patients on NOACs compared with patients on both NOACs and aspirin/antiplatelet drug. In this nonrandomized comparison, there was initially a signal toward higher thromboembolic rates among NOAC users also on aspirin/antiplatelet drugs (relative risk, 1.16; 95% confidence intervals, 1.05, 1.29) when compared with NOAC alone. This likely reflected the higher CHADS2 scores of those on aspirin/antiplatelet drugs. When the analysis was limited to studies that included aspirin rather than other antiplatelet drugs, no difference was seen for thromboembolic rates comparing dual therapy to NOAC alone (relative risk, 1.02; 95% confidence intervals, 0.90, 1.15). Higher rates of bleeding were seen with aspirin/antiplatelet drug in conjunction with NOAC. In this meta-analysis and nonrandomized comparison of aspirin/antiplatelet users and nonusers also on anticoagulation, there was no additional benefit seen of anticoagulation and antiplatelet therapy for stroke prevention when compared with anticoagulation alone. There was, however, an increased risk of bleeding. Careful assessment of the indications for antiplatelet drugs in patients with atrial fibrillation who are also receiving oral anticoagulants is warranted, and future randomized comparisons are needed.

Impact of Atrial Fibrillation and Sinus Rhythm Restoration on Reticulated Platelets

ObjectiveTo assess the impact of nonvalvular atrial fibrillation (NVAF) and sinus rhythm restoration on the distribution of reticulated platelets (RPs), which are known to be associated with thrombotic propensity and have a greater predilection for thrombus participation. Participants and MethodsThe RP content was assessed by flow cytometry (thiazole orange/CD61) in 110 consecutive patients with NVAF before and 3 to 4 months after catheter ablation of the pulmonary veins. Results were compared with those of 55 age- and sex-matched controls with normal sinus rhythm. ResultsThe mean ± SD percentage of RPs was higher in patients with NVAF compared with controls (28.5%±7.3% vs 6.4%±5.3%; P<.001). The RP content did not vary by CHA2DS2-VASc score. After catheter ablation of the pulmonary veins, 63 patients were available for follow-up assessment. A significant reduction of RPs was observed compared with preintervention values (29.85%±7.1% vs 20.79%±7.6%; P<.001). During follow-up, 19% of patients (12 of 63) had confirmed AF recurrence. The mean ± SD percentage of RPs was higher in this group than in those without a recurrence (24.7%±6.5% vs 18.9%±7.5%; P=.01). ConclusionNonvalvular atrial fibrillation affects the percentage of RPs, independent of the CHA2DS2-VASc score. After ablation, RP content dropped significantly. High RP content in patients with NVAF may explain the potential mechanism of thromboembolic complications and the lack of efficacy of currently available antiplatelet therapy for stroke prevention in this dysrhythmia.

Anticoagulant and antiplatelet therapy for stroke prevention in atrial fibrillation patients in the clinical practice of a single district hospital in Poland

Retrospective evaluation of stroke risk in all patients with atrial fibrillation (AF) admitted to cardiology, internal medicine, and neurology wards in a single Polish district hospital in 2006 and 2010 using two risk stratification schemes, CHADS₂ vs. CHA₂DS₂VASc risk scores and identification of independent predictors of guideline-compliant oral anticoagulant (OAC) treatment. We analysed case records of 613 patients with AF (including 300 patients in 2006 and 313 patients in 2010) treated in a district hospital - the John Paul II Western Hospital (Szpital Zachodni) in Grodzisk Mazowiecki, to evaluate their stroke risk and therapy prescribed at discharge. The mean patient age in the overall study population (49% of men) was 74.3 years (74.8, 77.5, and 71.9 years, respectively, in patients with paroxysmal, permanent and persistent AF). Patients > 75 years old comprised 58.6% of the study group, and those < 65 years old comprised 16.6% of the study group. The most common concomitant diseases were hypertension (65.9%), chronic heart failure (61.7%), coronary artery disease (43.1%), at least moderate mitral and/or tricuspid regurgitation (36.4%), and peripheral arterial disease (36%). Indications for OAC treatment were present in 85% (using the CHADS₂ score) or 95% (using the CHA₂DS₂VASc score) patients but this therapy was prescribed at discharge in only 39% of the study group (240 patients). Compared to patients who were not prescribed OAC, those prescribed OAC treatment were younger, more often male, with permanent AF, valvular heart disease, and hypertension. In patients without OAC treatment at discharge, the following conditions were found more frequently than in patients prescribed OAC treatment: paroxysmal AF(49.8% vs. 33.3% in OAC patients), established coronary artery disease (46.1% vs. 38.3%), previous myocardial infarction (27%vs. 18.7%), prior coronary revascularisation (11.2% vs. 6.6%), alcohol abuse (4.2% vs. 0.8%), renal failure (31.6% vs. 21.6%), and stroke or transient ischaemic attack (TIA; 19.3% vs. 12%). In multivariate logistic regression analysis, we identified 5 independent predictive factors associated with prescribing OAC at discharge, including persistent AF vs. paroxysmal AF (odd sratio [OR] = 5.27), permanent AF vs. paroxysmal AF (OR = 1.86), hypertension (OR = 1.50), previous stroke and/or TIA (OR = 0.59), and age > 75 years vs. < 65 years (OR = 0.53). Despite a high stroke risk as determined by both scores, only 39% of patients received OAC. In the studied population, independent predictors for prescribing OAC at discharge included arterial hypertension (in accordance with the guidelines) and younger patient age, no history of stroke/TIA, and AF other than paroxysmal. The practice of OAC and/or antiplatelet therapy use in AF patients discharged from a Polish district hospital was not compliant with the current ESC guidelines either in 2006 or in 2010.

Clopidogrel hydrogen sulphate for atrial fibrillation

Introduction: Atrial fibrillation is a common cardiac rhythm abnormality with a considerable cardiovascular disease burden worldwide. It is an independent major risk factor for stroke. Stroke prevention with anticoagulation or antiplatelet agents has been an important area of clinical research. Warfarin is the most widely used antithrombotic therapy for stroke prophylaxis for last several years, and now dabigatran (150 mg b.i.d.) is more effective than warfarin in stroke prevention in individuals at increased of stroke. In addition, several studies have evaluated the efficacy of clopidogrel for stroke prophylaxis either alone or in combination with aspirin.Areas covered: This review summarizes the key findings of the trials looking at the efficacy of clopidogrel in stroke prevention. A literature search was performed using PubMed and Google Scholar. The trials that evaluated the efficacy of clopidogrel in preventing atherothrombotic events or stroke were also included.Expert opinion: Clopidogrel prevents more vascular events, including stroke, in patients with a recent myocardial infarction, stroke or peripheral vascular disease than aspirin. Combination of clopidogrel and aspirin provides a greater reduction of stroke than aspirin or clopidogrel monotherapy, but at an increased risk of bleeding. Dual antiplatelet therapy (clopidogrel and aspirin) is inferior to warfarin in primary stroke prevention for patient with atrial fibrillation and thus should be considered for stroke prophylaxis only in patients ineligible for warfarin. However, with the advent of newer agents, like direct thrombin inhibitors and Factor Xa inhibitors, the role of antiplatelet therapy for stroke prevention in atrial fibrillation remains unclear.

Prevention of Thromboembolism in Atrial Fibrillation Patients

Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with substantial morbidity and mortality, particularly due to thromboembolic complications. Antithrombotic therapy reduces the risk of stroke and other thromboembolic events, with the greatest benefit seen in individuals at the highest absolute risk of stroke. There is increasing recognition of the superiority of oral anticoagulation over antiplatelet therapy for stroke prevention in atrial fibrillation. Nevertheless, oral anticoagulation is underused, especially in elderly people, which may in part be explained by uncertainty in the assessment of both risk of stroke and bleeding in an individual patient. The new European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation, which have recently been updated, recommend a risk-factor-based approach to thromboprophylaxis in patients with atrial fibrillation and provide practical tools for the assessment of individual risk. In this article we summarise strategies for prevention of thromboembolism in patients with atrial fibrillation as recommended by the ESC guidelines. New oral anticoagulants are also discussed.

Current issues in antiplatelet therapy for stroke prevention: the importance of stroke subtypes and differences between stroke and MI patients

Ischaemic stroke, the most common type of stroke, is classified into three main subtypes: large-vessel disease, lacunar or small-vessel disease, and cardioembolic; two further subtypes include a determined aetiology of "other" and cryptogenic. Although a substantial amount of literature exists concerning current guidelines for the secondary prevention of ischaemic stroke, treatment strategies for stroke subtypes as well as the reasons why these subtypes are significant have yet to be clearly defined. Furthermore, treatment strategies for secondary prevention of ischaemic stroke differ between patients who have suffered a previous stroke and those who have suffered a myocardial infarction. Antiplatelet therapies offer treatment that is as efficacious as warfarin, but with less severe bleeding. This review examines the importance of the different subtypes of stroke as well as differentiating between treating a heart patient and a stroke patient for secondary stroke prevention, including the advantages of using antiplatelet therapy over anticoagulants.

Advances in Antiplatelet Therapy for Stroke Prevention: the New P2Y12 antagonists

Thrombus formation at a site of arterial injury (eg, rupture of an atherosclerotic plaque in a carotid artery), a crucial step in the pathogenesis of cerebral ischemia, is initiated by the adhesion of platelets to the arterial wall. In vivo, activated platelets release adenosine diphosphate (ADP), whose binding to the platelet P2Y12 receptor elicits progressive and sustained platelet aggregation. As a result, this receptor has been a target for the development of clinically effective antiplatelet agents, such as the thienopyridines ticlopidine and, more recently, clopidogrel, the only two currently FDA-approved P2Y12 antagonists. Clopidogrel has a well-established role as an antithrombotic agent in the setting of ischemic stroke. However, several challenges remain, including the relatively slow onset of action of this drug and the phenomenon of clopidogrel response variability or "resistance". A number of novel P2Y12 antagonists are therefore under investigation to determine whether they can result in better or more rapid antithrombotic effects than clopidogrel, without an unacceptable increase in hemorrhagic (or other) side effects. These include 1) prasugrel, an orally-administered thienopyridine prodrug, 2) ticagrelor (AZD6140), an ATP analog reversible P2Y12 antagonist, 3) cangrelor, an intravenously-administered reversible P2Y12 antagonist, and 4) PRT060128. Whether the promising pharmacological profile of these drugs will be translated into clinical benefit for stroke patients will be determined by the results of clinical trials.

Dual Antiplatelet Therapy is not Optimal for Stroke Prevention in Patients with Atrial Fibrillation

The superior efficacy of oral anticoagulation over aspirin for prevention of recurrent stroke in patients with atrial fibrillation is widely acknowledged. However, oral anticoagulation therapy is notorious for having a narrow therapeutic index, numerous drug and dietary interactions, and a significant risk of serious bleeding. The value of dual antiplatelet therapy for stroke prevention in patients with atrial fibrillation has been assessed in the ACTIVE A trial. In this study, the relative risk of primary events was significantly decreased in patients allocated clopidogrel and aspirin compared with patients receiving aspirin alone. However, the relative risk of major bleeding was also significantly increased. This article analyses critically the role of dual antiplatelet therapy for stroke prevention in patients with atrial fibrillation.

Is Antiplatelet Therapy for the Prevention of Ischemic Stroke Associated with the Prognosis of Intracerebral Hemorrhage?

To examine whether antiplatelet therapy contributes to the unfavorable prognosis of intracerebral hemorrhage, we enrolled 253 consecutive patients (120 men and 133 women; 72.9+/-11.7 years) hospitalized in our institution within 24 hrs after onset of intracerebral hemorrhage. The location and size of intracerebral hemorrhage were determined from computed tomography (CT). Hematoma enlargement was identified on the basis of a second computed tomography scan performed on the day after admission. An unfavorable prognosis was defined as an outcome of worsening or death using the modified Rankin Scale (mRS). Locations of intracerebral hemorrhage (ICH) determined from CT were the thalamus in 92 patients (36.3%), putamen in 79 (31.2%), subcortex in 35 (13.8%), cerebellum in 20 (7.9%), brainstem in 18 (7.1%), and caudate nucleus in 9 (3.5%). Sizes of ICH were small and moderate in 153 patients (60%) and large in 100 (40%). Seventeen patients (6.7%) received antiplatelet therapy for stroke prevention. Hematoma enlargement was identified in 39 patients (15.4%). Overall outcomes at the time of discharge were unfavorable (modified Rankin Scale score 5-6) in 64 patients (25.2%) and favorable mRS score (0-1 approximately 4) in 189 (74.8%). Univariate analysis demonstrated that age >or=75 years (odds ratio: 2.78; 95%CI: 1.54-5.04) and presence of a large hematoma (odds ratio: 19.28; 95%CI: 8.84-42.1) were significantly related to the unfavorable prognosis. Using multiple logistic regression analysis after adjustments for age and sex, the presence of a large hematoma was still judged unfavorable; however, antiplatelet therapy was not related to unfavorable prognosis. Antiplatelet therapy may be unrelated to the unfavorable prognosis of ICH.

Antiplatelet therapy for stroke prevention

Recent trials of antiplatelet therapy for stroke prevention indicate that the combination of clopidogrel (75 mg/d) plus low-dose aspirin (75-162 mg/d) was not more effective than low-dose aspirin alone in the long-term prevention of major vascular events among patients at high risk of atherothrombotic events, nor was it more effective than oral anticoagulation in patients with atrial fibrillation. Furthermore, oral anticoagulation (International Normalized Ratio of 2.0-3.0) was not more effective than aspirin alone among patients with recent cerebral ischemia of presumed arterial origin. However, the addition of extended-release dipyridamole to aspirin was more effective than aspirin alone among patients with recent cerebral ischemia of presumed arterial origin. A large trial comparing clopidogrel with the combination of aspirin and extended-release dipyridamole in more than 20,000 patients with recent (< 120 days) atherothrombotic ischemic stroke is expected to report in 2008.

Counting the true cost of antiplatelet therapy for stroke prevention

Counting the true cost of antiplatelet therapy for stroke prevention

Update on antiplatelet therapy for stroke prevention.

The high rates of mortality and long-term disability associated with ischemic stroke, coupled with its prevalence, necessitate good, long-term preventive strategies. Risk-factor management is effective for individuals with preclinical and clinical cerebrovascular disease. Patients suffering from a transient ischemic attack or stroke are particularly vulnerable to subsequent stroke. Most of these individuals are candidates for antiplatelet treatment to prevent a recurrence. Available antiplatelet therapies include aspirin, ticlopidine, and clopidogrel. The combination of low-dose aspirin plus extended-release dipyridamole has been shown to offer safe, effective antiplatelet therapy for appropriate patients. In the second European Stroke Prevention Study, the combination was found to be significantly more effective than either drug alone, at the cost of relatively few treatment-related adverse effects. This combination is currently recommended as one of the first-line treatments for stroke prevention after first transient ischemic attack or stroke.

Gender differences in drug therapy.

Patient response to drug therapy is affected by multiple factors, including age, renal function, diet, smoking, congestive heart failure and gender. However, the data on gender differences in pharmacotherapy are limited, predominantly because women are excluded from clinical research due to the potential risks involved during pregnancy and co-existing illnesses in elderly women. Currently some information is available on gender differences in drug therapy. Differences in drug distribution and response due to different body composition as well as the effects of hormonal differences are the few that have been documented. Differences in drug metabolism due to differences in blood concentration of enzymes such as alcohol dehydrogenase has been recently described. Pharmacotherapy may also have to be altered due to differences in disease expression, like increased vasomotor tone in women. Drug efficacy has been found to be affected by gender---an example is antiplatelet therapy for stroke prevention. Finally, the side effects of drugs may differ depending on gender. Those involved in pharmacotherapy should be aware of these differences when prescribing drugs to female patients, since the majority of clinical data regarding pharmaceuticals has been derived primarily from a population of young males.

Update on Antiplatelet Therapy for Stroke Prevention

Aspirin is effective in reducing vascular outcomes in patients with atherosclerosis, with a relative risk reduction of about 30% for stroke, 22% for stroke and death and 15% for vascular mortality. Ap