A Comparison of Aspirin with Placebo in Patients Treated with Warfarin after Heart-Valve Replacement

Turpie, Alexander G. G.; Gent, Michael; Laupacis, Andreas; Latour, Y; Gunstensen, John; Basile, Fadi; Klimek, Marian; Hirsh, Jack

doi:10.1056/nejm199308193290802

Cited by 510 publications

(232 citation statements)

References 20 publications

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“…29 Careful patient selection for AVR and transcatheter AVR and appropriate anticoagulation, that is, for AF status, CHA 2 DS 2 -VASc score, and presence of additional coronary artery disease, therefore seem to be the modifiable risk factors for stroke prevention in AS, which may translate to improved post-AVR survival. 30 This hypothesis is further supported by reduced risk of stroke in (1) low-risk patients with AS with sinus rhythm, 31 (2) sufficiently anticoagulated post-AVR patients, 21 and (3) no detectable effect of intensive lipid-lowering in this study.…”

Section: Discussionsupporting

confidence: 61%

Stroke in Patients With Aortic Stenosis

Greve

Dalsgaard

Bang

et al. 2014

Stroke

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T he most recent US and European guidelines for treatment of valvular heart disease recommend oral anticoagulation (OAC) for stroke prophylaxis in all patients with aortic stenosis (AS) complicated by atrial fibrillation (AF).1,2 This recommendation differs from nonvalvular AF, where the decision to start OAC is guided by the CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years and female sex) risk scheme.3 The guideline discrepancy is based on observational studies indicating that calcific AS is an independent risk factor for stroke, 4 which may predict stroke even in the absence of AF.5 However, limited evidence exists on the effectiveness of the CHA 2 DS 2 -VASc scores in AS populations, and particularly in less severe AS where data are equivocal with regards to an increased stroke risk per se. 6 We hypothesized that calcific AS is associated with the same pathobiology underlying an increase in the CHA 2 DS 2 -VASc score and that the latter, therefore, could be particularly useful for stratifying risk of stroke in earlier stages of AS. This study was, therefore, undertaken to examine the ability of the CHA 2 DS 2 -VASc score to predict ischemic stroke in asymptomatic patients with AS with and without coexisting AF. Because risk of new-onset AF and thromboembolism may differ substantially in relation to aortic valve replacement (AVR) with or without coronary artery bypass grafting (CABG), the primary study hypothesis was stratified by AVR with and Background and Purpose-There are limited data on risk stratification of stroke in aortic stenosis. This study examined predictors of stroke in aortic stenosis, the prognostic implications of stroke, and how aortic valve replacement (AVR) with or without concomitant coronary artery bypass grafting influenced the predicted outcomes. Methods-Patients with mild-to-moderate aortic stenosis enrolled in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study. Diabetes mellitus, known atherosclerotic disease, and oral anticoagulation were exclusion criteria. Ischemic stroke was the primary end point, and poststroke survival a secondary outcome. Cox models treating AVR as a time-varying covariate were adjusted for atrial fibrillation and congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years and female sex (CHA 2 DS 2 -VASc) scores. Results-One thousand five hundred nine patients were followed for 4.3±0.8 years (6529 patient

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Section: Discussionsupporting

confidence: 61%

Stroke in Patients With Aortic Stenosis

Greve

Dalsgaard

Bang

et al. 2014

Stroke

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“…Both organizations suggest more intensive therapy (ie, INR 2.5-3.5) for patients with mechanical valves in the mitral position compared with the aortic position, regardless of prior embolism, and both organizations recommend addition of aspirin therapy to all patients with mechanical valves who are at low risk for bleeding. 523,524 Effective intervention for secondary prevention may be different for patients who have a first stroke before versus after mechanical valve replacement. Unfortunately, the evidence to refine decision making on the basis of this distinction has not yet been developed.…”

Section: Mechanical Valvesmentioning

confidence: 99%

Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack

Kernan¹,

Ovbiagele²,

Black³

et al. 2014

Stroke

3,994

1,326

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The aim of this updated guideline is to provide comprehensive and timely evidence-based recommendations on the prevention of future stroke among survivors of ischemic stroke or transient ischemic attack. The guideline is addressed to all clinicians who manage secondary prevention for these patients. Evidence-based recommendations are provided for control of risk factors, intervention for vascular obstruction, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke. Recommendations are also provided for the prevention of recurrent stroke in a variety of specific circumstances, including aortic arch atherosclerosis, arterial dissection, patent foramen ovale, hyperhomocysteinemia, hypercoagulable states, antiphospholipid antibody syndrome, sickle cell disease, cerebral venous sinus thrombosis, and pregnancy. Special sections address use of antithrombotic and anticoagulation therapy after an intracranial hemorrhage and implementation of guidelines.

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“…Esto se puede implementar en policlínicos generales con sistemas modernos más simples 18 y ajuste de dosis con sistemas automatizados. Por último, asociar dosis bajas de aspirina y mantener niveles más bajos de anticoagulación sin que esto signifique un aumento del tromboembolismo 20 . El uso de aspirina exclusiva (sin tratamiento anticoagulante asociado) ha sido reportado en forma esporádica en el pasado y es motivo de estudios prospectivos.…”

Section: Resultados De Reemplazo Valvular Aórtico Con Prótesis Mecániunclassified

Resultados del reemplazo valvular aórtico con prótesis mecánica en el Instituto Nacional del Tórax

T¹,

G²,

T³

2005

Rev. méd. Chile

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A Comparison of Aspirin with Placebo in Patients Treated with Warfarin after Heart-Valve Replacement

Cited by 510 publications

References 20 publications

Stroke in Patients With Aortic Stenosis

Stroke in Patients With Aortic Stenosis

Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack

Resultados del reemplazo valvular aórtico con prótesis mecánica en el Instituto Nacional del Tórax

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