Aspirin or Anticoagulants in Stenosis of the Middle Cerebral Artery:A Randomized Trial

Martí‐Fàbregas, Joan; Cocho, Dolores; Martí-Vilalta, Josep-Lluis; Gich, Ignasi; Belvís, R.; Bravo, Yolanda; Millán, Mònica; Castellanos, Mar; Rodríguez-Campello, Ana; Egido, J.; Geffner, D; Gil-Núñez, A.; Marta, J.; Navarro, Roberto Campos; Obach, Vı́ctor; Palomeras, Ernest

doi:10.1159/000093450

Cited by 18 publications

(13 citation statements)

References 66 publications

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“…385,[565][566][567][568][569][570] Most of these trials enrolled patients with heterogeneous causes of stroke such as large-artery extracranial or intracranial atherosclerosis, small-vessel disease, or cryptogenic stroke, but 2 of these studies 385,568 restricted enrollment to patients presenting with TIA or stroke related to atherosclerotic intracranial arterial stenosis. None of these randomized trials have shown a benefit of VKAs over antiplatelet therapy for preventing recurrent stroke, whereas some of these trials have shown an increased risk of major hemorrhage in the VKA arm.…”

Section: Oral Anticoagulantsmentioning

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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Section: Oral Anticoagulantsmentioning

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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“…Aspirin has been shown to reduce the risk of stroke [1] and is the treatment of choice for the prevention of vascular events in patients with symptomatic middle cerebral artery (MCA) stenosis [2]. Standard extracranial-intracranial (EC-IC) arterial bypass surgery is a treatment option to revert hemodynamic compromise in order to avoid recurrent ischemic stroke in patients with symptomatic, chronic, hemodynamic insufficiency [3,4,5,6].…”

Section: Introductionmentioning

confidence: 99%

Aspirin Resistance in Patients with Hemodynamic Cerebral Ischemia Undergoing Extracranial-Intracranial Bypass Surgery

Jussen¹,

Horn²,

Vajkoczy³

2013

Cerebrovasc Dis

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Background: Aspirin (acetylsalicylic acid, ASA) is the treatment of choice for prevention of vascular events in symptomatic steno-occlusive cerebrovascular disease (CVD). Cerebral revascularization using standard extracranial-intracranial (EC-IC) bypass surgery may be used to revert hemodynamic compromise. Aspirin is prescribed as standard medication in order to avoid bypass failure. Accumulating evidence of an increased risk of major adverse clinical events led to this study, in which we aimed to assess the prevalence of aspirin resistance and prothrombotic disorders among patients scheduled for EC-IC bypass surgery, and the effectiveness of aspirin dose escalation. Methods: We prospectively screened patients with circumscribed high-grade stenosis or occlusion of brain-supplying vessels fulfilling the hemodynamic criteria for EC-IC bypass surgery for aspirin resistance using a platelet function analyzer (PFA-100®) test. We also determined their smoking habits and screened for prothrombotic disorders and comorbidities. The patients were divided into 2 major groups: group A had atherosclerotic steno-occlusive CVD and group B consisted of patients with nonatherosclerotic steno-occlusive CVD (moyamoya disease) and a subgroup of pediatric moyamoya patients (pediatric subgroup). Bypass patency was documented via digital subtraction angiography. Standard initial ASA dose applied was 100 mg/day. In cases of aspirin resistance, doses were increased and the PFA-100 test was repeated. Results: A total of 56 patients were included over a time period of 6 months. In group A (n = 25), we found a ratio of 40% of patients with primary resistance to aspirin 100 mg/day. In contrast, in group B (n = 25), only 20% of the patients were resistant to aspirin 100 mg/day; in the pediatric population (n = 6), there was no primary aspirin resistance. After a dose escalation to 300 mg/day, the ratio of aspirin resistance was reduced to 20% in group A and to 0% in group B. Altogether 5 patients with atherosclerotic steno-occlusive CVD remained aspirin-resistant despite the dose escalation; 2 of them suffered an early bypass failure. Smoking habits and diabetes mellitus were positively correlated with aspirin resistance. Moreover, 25% of all patients had laboratory signs of a prothrombotic disorder, but this had no influence on aspirin response or bypass patency. Conclusions: Aspirin resistance is common in the population of patients with hemodynamic cerebral ischemia scheduled for cerebral revascularization. It may have an adverse impact on the outcome of surgery. Screening and treatment via dose escalation of aspirin is a straightforward and sensible routine for patients undergoing EC-IC bypass surgery.

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“…Among trials the different event rates may be attributed to study design features, the vascular risk profile of the included patients and the intensity of cointerventions for other vascular risk factors or comorbidity. Restricting access to the randomized trial to patients with high-risk conditions like atrial fibrillation or large-artery atherosclerosis will increase the number of endpoints [3,4,5,6]. Including only patients with multiple risk factors or previous vascular events may also increase the endpoint rate.…”

Section: Introductionmentioning

confidence: 99%

Is There a Decline in the Vascular Event Rate after Transient Ischemic Attack or Stroke in Antiplatelet Trials?

Lemmens

Chen²,

Ni³

et al. 2009

Cerebrovasc Dis

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Background: We examined the baseline characteristics and the rates of serious vascular events in randomized clinical trials after cerebral ischemia of presumed arterial origin to identify study features that predict vascular event incidence and to identify whether event rates have declined over time. Methods: We performed a systematic review to identify all published randomized controlled trials of patients with stroke or transient ischemic attack of presumed arterial origin that included an aspirin arm. We performed metaregression to analyze whether baseline features of included patients, design features and the year of study start and publication influenced vascular event rates under aspirin treatment. Results: Included studies comprised 23,247 patients who had 3,615 serious vascular events. Baseline characteristics of patients included in the different trials varied substantially over time. In multivariate metaregression analysis a shorter maximum allowed delay from symptom onset to randomization (p = 0.012) and a double-blind design were associated with higher annual event rates (p = 0.014). Event rates did not significantly decrease over time (p = 0.242). Conclusion: The baseline characteristics of patients included in trials that study antiplatelet agents have changed over time. The strongest predictors for higher event rates are a double-blind design and a short delay between symptom onset and randomization. An important reduction in event rates over time could not be demonstrated.

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Aspirin or Anticoagulants in Stenosis of the Middle Cerebral Artery:A Randomized Trial

Cited by 18 publications

References 66 publications

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

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

Aspirin Resistance in Patients with Hemodynamic Cerebral Ischemia Undergoing Extracranial-Intracranial Bypass Surgery

Is There a Decline in the Vascular Event Rate after Transient Ischemic Attack or Stroke in Antiplatelet Trials?

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