Comparison between single antiplatelet therapy and combination of antiplatelet and anticoagulation therapy for secondary prevention in ischemic stroke patients with antiphospholipid syndrome

Abstract

Satisfactory results have not yet been obtained in therapy for secondary prevention in ischemic stroke patients with antiphospholipid syndrome (APS). We therefore compared single antiplatelet therapy and a combination of antiplatelet and anticoagulation therapy for secondary prevention in ischemic stroke patients with APS. The subjects were 20 ischemic stroke patients with antiphospholipid antibody, 13 with primary antiphospholipid syndrome and 7 with SLE-related antiphospholipid syndrome. Diagnosis of APS was based on the 2006 Sydney criteria. Eligible patients were randomly assigned to either single antiplatelet therapy (aspirin 100 mg) or a combination of antiplatelet and anticoagulation therapy (target INR: 2.0-3.0; mean 2.4±0.3) for the secondary prevention of stroke according to a double-blind protocol. There was no significant difference between the two groups in age, gender, NIH Stroke Scale on admission, mRS at discharge, or rate of hypertension, diabetes mellitus, hyperlipidemia, or cardiac disease. We obtained Kaplan-Meier survival curves for each treatment. The primary outcome was the occurrence of stroke. The mean follow-up time was 3.9±2.0 years. The cumulative incidence of stroke in patients with single antiplatelet treatment was statistically significantly higher than that in patients receiving the combination of antiplatelet and anticoagulation therapy (log-rank test, p-value=0.026). The incidence of hemorrhagic complications was similar in the two groups. The recent APASS study did not show any difference in effectiveness for secondary prevention between single antiplatelet (aspirin) and single anticoagulant (warfarin) therapy. Our results indicate that combination therapy may be more effective in APS-related ischemic stroke.

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

“…703 A small clinical trial of 30 patients with ischemic stroke and antiphospholipid antibodies suggested that the combination of aspirin and anticoagulation may be more effective than aspirin alone in preventing recurrent stroke. 704 In summary, therefore, the evidence to guide therapy in stroke patients who meet the case definition for the APS is incomplete.…”

Thrombotic recurrences and bleeding events in APS vascular patients: A review from the literature and a comparison with the APS Piedmont Cohort

“…Okuma et al [31] enrolled 20 APS stroke patients according to the Sydney criteria. They were randomized to receive aspirin 100 mg or aspirin 100 mg associated to OAT, with INR 2-3.…”

Direct thrombin inhibitors and factor Xa inhibitors in patients with cerebrovascular disease

“…Whether novel anticoagulants may offer advantages as alternative anticoagulant treatment in patients remains untested. Although anticoagulation is indicated for cerebral venous thrombosis in patients with antiphospholipid antibody syndrome, anticoagulation has not been proven to be superior to aspirin for arterial ischemic stroke prevention in these patients [34]. Trials evaluating the efficacy of novel DTIs or factor Xa inhibitors for arterial stroke prevention in patients with APAS are clearly needed.…”