Antithrombotic therapy for secondary prevention in patients with stroke or transient ischemic attack: A multiple treatment network meta-analysis of randomized controlled trials

Abstract

Objective As stroke represents one of the leading causes of mortality and disability worldwide, we aimed to determine the preventive effect of different antiplatelet therapies after an ischemic stroke or transient ischemic attack. Methods Network meta-analysis evaluating antiplatelet regimes after an ischemic stroke or transient ischemic attack. Searches were conducted in MEDLINE, EMBASE, and Cochrane Library databases until Nov. 23, 2021, for randomized controlled trials. Direct comparisons within trials were combined with indirect evidence from other trials by using a frequentist model. An additive network meta-analysis model was used to evaluate the influence of individual components. The primary efficacy endpoint was a recurrent stroke, the main safety outcomes were the risk of major bleeding and mortality at the longest available follow-up. Results 58 randomized controlled trials (175,730 patients) were analyzed. The analysis involved 20 antithrombotic strategies including different antiplatelet agents, combinations with aspirin, and anticoagulant therapies. Cilostazol proved to be the most efficacious in reducing stroke recurrence and the risk of bleeding (RR = 0.66, 95%CI = 0.55–0.80 and RR = 0.39, 95%CI = 0.08–2.01) compared to aspirin, respectively. Intensification with combinations of aspirin with ticagrelor or clopidogrel resulted in a lower risk of stroke recurrence (RR = 0.79, 95%CI = 0.67–0.93 and RR = 0.79, 95%CI = 0.72–0.87) but carried a higher bleeding risk (RR = 3.01, 95%CI = 1.65–5.49 and RR = 1.78 95%CI = 1.49–2.13). Conclusion The prognosis of patients with an ischemic stroke or transient ischemic attack is improved with antiplatelets. Cilostazol showed the best risk-benefit characteristics without trade-off with the risk of major bleeding. Improved stroke recurrence with intensified antiplatelet regimens is counterbalanced with higher bleeding risk, and consequently, mortality remains unaffected. Treatment decisions in stroke survivals should integrate the assessment of bleeding risk for better identification of patients with the highest benefit of treatment intensification. Systematic review registration Prospero registration number: CRD42020197143, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=197143.

Left Ventricular Ejection Fraction Association with Acute Ischemic Stroke Outcomes in Patients Undergoing Thrombolysis

“…In the preventive treatment of LVSD, especially in AIS patients with strong cardiovascular risk factors such as AF and IHD, newer studies support the use of combination antiplatelet and anticoagulant therapy in cardiovascular prevention [ 58 , 59 ], with some stressing the importance of antiplatelet therapy [ 60 ] and even antithrombotic therapy [ 61 ]. Admittedly, this might further increase the risk of complications, such as heightened bleeding risk, especially in the AIS patient population undergoing IV thrombolysis [ 62 ].…”

Hematocrit Predicts Poor Prognosis in Patients with Acute Ischemic Stroke or Transient Ischemic Attack

“…Our sensitivity analysis shows that the association between HCT and all-cause mortality attenuated upon the exclusion of recurrent stroke cases, which implies that the correlation between HCT and all-cause mortality is mainly attributed to stroke recurrence during the follow-up period, rather than having a significant intrinsic relationship. It is important to note that the judicious selection of different treatment regimens can influence the prognosis of patients with ischemic stroke [38,39]. The complex interactions and adverse effects between antiplatelet therapy, anticoagulation therapy, and interventional treatments may also have varying impacts on patient outcomes [40,41].…”

Endovascular Treatment for Acute Basilar Artery Occlusion: A Fragility Index Meta-Analysis

“…These differences also have treatment implications, since it has been shown that recanalization rates are higher in patients with distal BAO occlusions [ 28 ]. Furthermore, among all stroke subtypes, adjunctive pharmacotherapy, such as antiplatelet agents and anticoagulants, either in the acute–subacute phase or as secondary stroke prevention measures, may inherently influence the efficacy and safety following acute reperfusion therapies [ 29 , 30 ].…”