Secondary Stroke Preventiona Trials

Question 1

ATC

Antiplatelet Trialists Collaboration

Answer 1

60,196 pts with atherosclerosis

ASA at 50-1500mg/day

23% odds reduction in the composite outcome of MI, stroke, or vascular death

highest RRR was seen in low 75-150 and
medium dose 160-325 mg

Question 2

CATS

Canadian American Ticlopidine Study

Answer 2

1072 patients with recent thromboembolic stroke Ticlopidine 250mg BID vs placebo

Ticlopidine reduced the risk of composite outcome of MI, stroke and vascular death by 30%

Question 3

TASS

Ticlopidine Stroke Study

Answer 3

2069 pts with recent TIA o cerebral infarction
tcilopidine 250mg BID vs ASA 1300mg/day

Ticlopidine reduced the risk of stroke or death at 3 years by 12 relative to ASA

Neutropenia was more common with Ticlopidine

Question 4

CAPRIE

Clopidogrel vs ASA at Risk of Ischemic Events

Answer 4

19, 185 pts with atherosclerotic disease
clopidogrel 75mg/day vs ASA 325 mg/day

at 1.6 years clopidogrel reduced the combined endpoint of ischemic stroke MI vascular death by 8.7% relative to ASABenefit was greater in pts with PAD

Question 5

MATCH

Management of Atherothrombosis with Clopidogrel in High Risk Patients with TIA or stroke

Answer 5

7,599 patients with prior stroke or TIA and additional risk factors
clopid 75 + ASA 75 vs
clopid 75

NO SIGNIFICANT DIFFERENCE between groups in the combined endpoint of ischemic stroke MI vascular death or rehospitalization at 18 months

SIGNIFICANT INCREASE IN MAJOR BLEEDING with COMBI TX

Question 6

CHARISMA

Clopidogrel for High Atherothrombotic Risk and Ischemic stabilization, Management and Avoidance

Answer 6

15,603 pts with either clinicaly evident CardioVasc disease or with multiple risk factors were randomized to
clopid 75 with low dose ASA 75-162
low dose ASA

Overall, clopidogrel plus ASA was not significantly more effective than ASA alone in reducing rate of MI, stroke, or vascular death

there was suggestion of benefit of combination treatment among patients with atherosclerotic disease

There was significant increase in major bleeding with combi treatment

Question 7

SPS 3

Secondary Prevention of Small Subcortical Strokes

Answer 7

3,020 patients
recent symptomatic lacunar infarction within 180 days by MRI were randomized to

clopid 75 + ASA 325 mg
or ASA 325 mg

ffup of 3.4 yrs
rate of recurrent stroke was not significantly different between the 2 groups
(Clopid + ASA 2.5% vs ASA 2.7% per year)

The risk of Major bleeding and all cause mortality was significantly increased in the DAPT

Question 8

CSPS

Cilostazol Stroke Prevention Study

Answer 8

10995 pts with cerebral infarction in the past 6 months were randomized to

cilostazol 100mg BID vs placebo

active treatment with cilosatzol reduced the risk of recurrent ischemic stroke by 41.7

Question 9

CSPS 2

Cilostazol Stroke Prevention Study 2

Answer 9

2757 pts with cerebral infarction within the previous 26 weeks

cilostazol 100mg BID vs ASA 81 mg OD
1-5 yrs

annual occurrence of stroke (infarction, ICh, SAH) was 2.76% in cilostazol vs 3.71% in ASA
PRIMARY OUTCOME OF NON-INFERIORITY

hemorrhagic events occurred less but headache, tachycardia and diarhhea were frequent in cilostazol group

Question 10

TOSS 1

Trial of Cilostazol in Symptomatic Intracranial Stenosis 1

Answer 10

135 pts with recent ischemic stroke within 2 weeks due to symptomatic MCA or basilar artery stenosis by MRi/MRA were randomized

cilostazol 100mg BID + ASA 100mg vs
ASA 100 mg OD
x 6 months

progression of symptomatic intracranial stenosis was significantly lower with cilostazol +ASA than ASA alone

Question 11

TOSS 2

Trial of Cilostazol in Symptomatic Intracranial Stenosis 2

Answer 11

457 pts with acute ischemic stroke within 2 weeks secondayr to stenosis of the MCA or basilar artery were randomized

cilostazol 100mg BID + ASA 100mg OD vs
clopidogrel 75 mg + ASA 100mg OD
x 6 months

no significant difference in progression of symptoms
favorable changes in lipoprotein profiles and a trend towards less hemorrhagic complications were observed in the cilostazol treated group

Question 12

ESPS 1

European Stroke Prevention Study 1

Answer 12

2500 pts with strokes or TIAs were randomized
ASA 975mg + dipyridamole 225mg/d
vs placebo

active treatment with ASA + dipyridamole reduced the risk of stroke and death by 33%

Question 13

ESPS 2

European Stroke Prevention Study 2

Answer 13

6602 pts with recent TIA or stroke
ASA 25mg BID 
ER DP 200mg BID 
ASA + DP
placebo
x 2 years

stroke reduction compared to placebo were
ASA 18%
ER DP 16%
ASA + DP 37.8%

there was no increased risk of bleeding with combi

Question 14

ESPRIT

European/Australasian Stroke prevention in Reversible Ischemia Trial

Answer 14

2,739 pts with recent TIA or minor stroek were randomized to

ASA 30-325mg/day + DP 200 mg BID
ASA 30-325mg

composite outcome of stroke, MI, death were reduced by 20% with ASA + DP relative to ASA alone

There was no increased risk of bleeding with combi tx

Question 15

PROFESS
Prevention Regimen for Effectively Avoiding Sceond Strokes
Clopidogrel vs ASA-DP

Answer 15

20,332 pts with rcent stroke within the past 120 days were randomized to ASA 25 mg + ER DP 200 mg BID or clopidogrel 75 mg/day

Similar rates of recurrent ischemic stroke at median follow-up of 2.5 years between groups

there were major hemorrhagic events with ASA-Dp 4.1 % vs Clopidogrel 3.6

Question 16

TACIP

Triflusal Aspirin Cerebral infarction Prevention

Answer 16

2113 patients with recent TIA or ischemic stroke within the past 6 months were randomized to

triflusal 600mg/day
ASA 325mg/day

for median follow-up for 30 months

similar efficacy between groups in combined endpoint, stroke, MI vascula rdeath

Triflusal was associated with significantly less risk of hemorrhagic complications

Question 17

TAPIRSS

Triflusal vs Aspirin in the Prevention of Infarction: A Randomized Stroke Study

Answer 17

431 patients with recent TIA or ischemic stroke within the past 6 months were randomized

triflusal 600mg/day
ASA 325mg/day for mediam ffup 28 months

no significant difference in the combined endpoint
Triflusal was associated with significantly less overalrisk of hemorrhagic complications

Question 18

WARSS

Warfarin-Aspirin Recurrent Stroke Study

Answer 18

12,206 pts with a prior non-cardioembolic stroke
randomized
warfarin (INR 1.4-2.8) or
ASA 325mg/day

no difference between groups in recurrent ischemic stroke or death at 2 years (warfarin 17.8% vs ASA 16%)

Question 19

WASID

Warfarin-Aspirin in Symptomatic Intracranial Disease

Answer 19

Pts with stroke or TIA caused by 50-99% stenosis of a major intracranial artery were randomized to dose adjusted warfarin or ASA 1300mg/day

No significant difference in 2 year ischemic stroke rates between groups
warfarin 17.2% vs ASA 19.7%

Question 20

CHANCE

Clopidogrel in High Risk Patients with Acute Nondisabling cerebro vascular Event

Answer 20

demonstrated thebenefit of short term DAPT when given within 24 hrs of ischemic stroke and TIA