Antithrombotic Therapy for Secondary Prevention in Patients with Non-Cardioembolic Stroke or Transient Ischemic Attack: A Systematic Review

Abstract

Stroke embodies one of the leading causes of death and disability worldwide. We aimed to provide a comprehensive insight into the effectiveness and safety of antiplatelet agents and anticoagulants in the secondary prevention of ischemic stroke or transient ischemic attack. A systematic search for randomized controlled trials, comparing antiplatelet or anticoagulant therapy versus aspirin or placebo among patients with ischemic stroke or transient ischemic attack, was performed in order to summarize data regarding the different regimens. Keyword-based searches in the MEDLINE, EMBASE, and Cochrane Library databases were conducted until the 1st of January 2021. Our search explored 46 randomized controlled trials involving ten antiplatelet agents, six combinations with aspirin, and four anticoagulant therapies. The review of the literature reflects that antiplatelet therapy improves outcome in patients with ischemic stroke or transient ischemic attack. Monotherapy proved to be an effective and safe choice, especially in patients with a high risk of bleeding. Intensified antiplatelet regimens further improve stroke recurrence; however, bleeding rate increases while mortality remains unaffected. Supplementing the clinical judgment of stroke treatment, assessment of bleeding risk is warranted to identify patients with the highest benefit of treatment intensification.

Cardiovascular medications and long‐term mortality among stroke survivors in the Brazilian Study of Stroke Mortality and Morbidity (EMMA)

“…18 Also, data from a recent systematic review involving 46 randomized clinical trials (10 anti-platelet agents, 6 combinations with aspirin, and 4 OACs) revealed that anti-platelets improved outcomes for IS or transient ischemic attacks. 19 Previous analyses from the EMMA study also revealed an impressive reduction in long-term mortality rates among those with AF stroke under warfarin use longer than 6 months after the acute event. 20 Of note, the main barriers to effective anti- | 719 coagulation therapy in LMICs such as Brazil are the still high cost of direct oral anti coagulant and the lack of sites to periodically perform international normalized ratio control for those AF stroke cases, which impacts morbidity and mortality after a stroke event, particularly in the low-income population, 21 as is the case for the participants from the EMMA cohort.…”

“…For example, blood pressure (BP) control with anti‐hypertensive drugs drastically reduces the risk of a second event or death 18 . Also, data from a recent systematic review involving 46 randomized clinical trials (10 anti‐platelet agents, 6 combinations with aspirin, and 4 OACs) revealed that anti‐platelets improved outcomes for IS or transient ischemic attacks 19 …”

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 ].…”

Possibilities of antiplatelet therapy in non-cardioembolic ischemic stroke

“…Проведенные исследования показали эффективность и безопасность применения цилостазола для профилактики повторного ИИ в странах Азии. Однако данные об использовании цилостазола в других этнических группах остаются недостаточными [36]. Метаанализ, включающий 16 рандомизированных клинических исследований, посвященных двойной антитромбоцитарной терапии (сочетание клопидогрела с АСК, ДП с АСК, цилостазола с АСК и тикагрелора с АСК), назначенной в первые 72 ч некардиоэмболического ИИ или ТИА, охвативший 28 032 пациента, подтвердил уменьшение риска развития повторного ИИ [относительный риск (ОР) 0,75; 95% ДИ 0,68-0,83; р<0,00001] и тяжелых сердечно-сосудистых осложнений (ИМ и смерти от сердечно-сосудистых причин; ОР 0,73; 95% ДИ 0,65-0,82; р<0,00001) по сравнению с монотерапией АСК.…”

“…Риск геморрагических осложнений не различался между группами (ОР 1,22; 95% ДИ 0,87-1,70; р=0,25) [37]. Однако вопросы безопасности длительной двойной антитромбоцитарной терапии инициируют дальнейший поиск оптимальных режимов ее применения [4,36].…”