ISCHEMIC STROKE Flashcards
Patients were randomized to either combination aspirin plus clopidogrel or aspirin monotherapy and followed prospectively for CV events including MI, stroke, or death due to CV cause.
With median follow-up of 2.3 years, rates of composite outcome of MI, stroke, or CV-related death were observed at similar rates between groups (6.8% vs. 7.3%). There was increased bleeding in the combination therapy group
Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events
CHARISMA
clopidogrel reduced the risk of CV events by 9% compared to aspirin without an adverse effect on bleeding events.
A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events
CAPRIE
Those with symptomatic 50-69% stenosis had a 29% reduction in the 5-year risk of death or stroke, while those with <50% stenosis had no such benefit.
Those with ≥70% stenosis received such a dramatic benefit that this study arm was prematurely stopped and all patients with severe stenosis were subsequently referred for CEA.
Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis
NASCET
Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack
reduction of blood pressure is beneficial for secondary prevention of stroke in both hypertensive and normotensive patients. Treatment with combination therapy with indapamide and perindopril decreased blood pressure and recurrence of stroke.
PROGRESS
randomized 20,332 patients with a noncardioembolic ischemic stroke within the previous 90-120 days to either aspirin-dipyridamole or clopidogrel.
At a mean follow-up of 2.5 years, there was no difference in the primary outcome of any recurrent stroke (9.0% vs. 8.8%) or the composite secondary outcome of stroke, MI, or CV death.
Compared with clopidogrel, aspirin-dipyridamole was associated with less heart failure but more major hemorrhages including intracranial hemorrhages, and more discontinuation of treatment due to adverse events, mainly headaches, the most common side effect of dipyridamole.
The Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS)
randomized 7,599 patients with recent ischemic stroke/TIA and at least one additional CV risk factor to either combination therapy with aspirin plus clopidogrel or single-agent clopidogrel.
At a mean follow-up of 18 months,it failed to demonstrate a statistically significant difference in efficacy between the two groups. However, there were more major bleeding events with combination therapy, including life-threatening bleeding.
Management of Atherothrombosis with Clopidogrel in High-risk patients (MATCH)
two of the largest trials to study aspirin in acute ischemic stroke.
IST and CAST
The _________demonstrated a 28% reduction in 14-day recurrence of ischemic stroke, and a 9% reduction in the combined outcome of nonfatal stroke or death at 14 days.
International Stroke Trial (IST)
________demonstrated a 14% reduction in all-cause mortality at 4 weeks
CAST
At 90 days, combination aspirin/clopidogrel was associated with a 3.5% absolute and a 30% relative reduction in subsequent strokes compared to aspirin monotherapy
Clopidogrel in High-risk patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial
The ___________therapy in CHANCE is one of the most significant differences between it and MATCH, and is likely the reason that CHANCE was a positive trial.
early use of combination antiplatelet
1995 __________was the first to establish efficacy of thrombolysis within a 3-hour time frame for ischemic stroke.
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study (NINDS)
demonstrated a benefit of intravenous alteplase beyond the conventional 3-hour time window established in the NINDS trial (1995), effectively extending the window for alteplase to 4.5 hours
Of note, patients with severe signs of stroke were excluded, and the placebo group had higher rates of prior stroke, which may have accounted for the worsened outcomes.
2008 European Cooperative Acute Stroke Study III (ECASS III)
2,739 patients with TIA or minor ischemic stroke to combination aspirin/dipyridamole or aspirin alone in an unblinded fashion
3.5 years, combination aspirin/dipyridamole was associated with an absolute risk reduction of 1% per year for the composite primary outcome of vascular mortality, non-fatal stroke, non-fatal MI, or major bleeding
Bleeding rates were similar between the two groups. Combination aspirin/dipyridamole was discontinued secondary to headaches 8.8% of patients.
European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT)
Alteplase was non-significantly associated with lower infarct growth and significantly associated with increased reperfusion in patients who had mismatch perfusion-weighted MRI (PWI) and diffusion-weighted MRI (DWI).
EPITHET
