One Year after CAPRIE, IST and ESPS 2

Abstract

The IST, CAPRIE and ESPS-2 have shown that large collaborative randomised trials can be conducted in stroke medicine and can provide statistically and clinically significant results. They, and other concurrent studies, have highlighted the potential hazards of early anticoagulation, and the effectiveness and safety of early (and continuous) antiplatelet therapy in limiting early stroke recurrence and its consequences. In addition, they have shown that antiplatelet agents with differing mechanisms of action can have different effects, and perhaps additive effects when combined. The ESPRIT trial should delineate the roles of oral anticoagulant therapy, and the combination of aspirin and dipyridamole, in the prevention of stroke due to arterial disease. Future trials will hopefully determine the role in secondary stroke prevention of inhibitors of the platelet GPIIb/IIIa complex (the final common pathway of platelet aggregation), the combination of anitplatelet agents with different mechanisms of action (e.g. aspirin and clopidogrel, aspirin and IIb/IIIa inhibitors), the combination of antiplatelet agents and oral anticoagulants (which may simultaneously modify platelet function and fibrin production), and the combination of antithrombotic and cholesterol-lowering (statin) medications.

Secondary Prevention Strategies in Ischemic Stroke: Identification and Optimal Management of Modifiable Risk Factors

“…Antiplatelet agents, including aspirin, ticlopidine, clopidogrel, and extended-release dipyridamole and aspirin have proved valuable in the secondary prevention of ischemic stroke. [15][16][17] Also, randomized trial evidence supports secondary prevention strategies for the treatment of hypertension, 18,19 hyperlipidemia, 20,21 symptomatic carotid disease, 22 and atrial fibrillation, 14,23 as well as use of coordinated acute stroke units. 24 Observational data suggest that control of diabetes 13 and smoking cessation reduce the risk of second stroke or cardiac disease.…”

Management of the first‐time transient ischaemic attack

“…Aspirin in combination with dipyridamole may be more effective than aspirin alone, by about 15% (range 4–26%), 19,31 but further trials (e.g. ESPRIT) are in progress.…”

Intravenous Heparin Therapy in Acute Ischaemic Cerebral Infarct: Contra

“…In dieser so genannten FISS oder Hongkong-Studie wurde unter Nadroparin eine 31 % relative Risikoreduktion für Tod oder schwere Behinderung nach 6 Monaten gefunden (45 vs. 65 %, Nadroparin vs. Plazebo). Die Daten wurden allerdings durch die wenig vergleichbaren Gruppen (mehr schwere Schlaganfälle in der Plazebogruppe) allgemein als nicht verlässlich empfunden [18,19]. Auûerdem ist die Patientenpopulation nach heutigen Kenntnissen viel zu klein.…”