scholarly journals Secondary Stroke Prevention, and the Role of Antiplatelet Therapies

2009 ◽  
Vol 1 ◽  
pp. CMT.S2208
Author(s):  
Howard S. Kirshner
Keyword(s):  
Risk Factor ◽  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Extended Release ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Internal Carotid Artery Stenosis ◽  
Secondary Stroke Prevention ◽  
First Line

This review considers treatments of proved efficacy in secondary stroke prevention, with an emphasis on antiplatelet therapy. Most strokes could be prevented, if readily available lifestyle and risk factor modifications could be applied to everyone. In secondary stroke prevention, the same lifestyle and risk factor modifications are also important, along with anticoagulation for patients with cardiac sources of embolus, carotid procedures for patients with significant internal carotid artery stenosis, and antiplatelet therapy. For patients with noncardioembolic ischemic strokes, FDA-approved antiplatelet agents are recommended and preferred over anticoagulants. ASA, clopidogrel, and ASA + ER-DP are recognized as accepted first-line options for secondary prevention of noncardioembolic ischemic stroke. Combined antiplatelet therapy with ASA + clopidogrel has not been shown to carry benefit greater than risk in stroke or TIA patients. Aspirin and extended release dipyridamole appeared to carry a greater benefit over aspirin alone in individual studies, leading to a recommendation of this agent in the AHA guidelines, but the recently completed PRoFESS trial showed no difference in efficacy between clopidogrel and aspirin with extended release dipyridamole, and clopidogrel had better tolerability and reduced bleeding risk.

Abstract W P155: Antiplatelet Therapy Benefit in Secondary Stroke Prevention in Patients With Suboptimally Controlled Treatable Cerebrovascular Risk Factors

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Muhammad Umer ◽  
Kateryna Kurako ◽  
Nestor Galvez-Jimenez ◽  
Efrain Salgado
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Antiplatelet Agents ◽  
Large Artery ◽  
Secondary Stroke Prevention ◽  
Risk Factor Control ◽  
Cerebrovascular Risk Factors ◽  
Cerebrovascular Risk

Objective: To assess the impact of antiplatelet therapy for secondary stroke prevention in patients with suboptimally controlled treatable cerebrovascular risk factors per guidelines. Results: Of the 1755 patients, 219 (12.47%) patients had a second stroke event between November 2006-December 2012. Mean age of this group of patients was 66.4 years old with male predominance (M:F=1.5:1). 192 (88%) patients were on antiplatelet therapy at the time of the second stroke. 27 (12 %) were not on antiplatelet therapy. Of the total cohort, treatable risk factors were poorly controlled in 130 (59%) patients: 121 (55%) hypertension; 78 (36%) hyperlipidemia, 44 (20%) diabetes. Antiplatelet agents included aspirin, clopidogrel alone or in combination with aspirin, and extended-release dipyridamole. The data showed no significant difference among antiplatelet agents for secondary stroke prevention (p<0.05). Stroke classification was as follows: 162 (74%) ischemic and 57 (26%) hemorrhagic. Categories of ischemic stroke were as follows: large-artery atherosclerosis 40 (18%), small vessel disease 45 (21%), cardioembolic 42 (19%), 35 (16%) cryptogenic / stroke of undetermined etiology. Of the 192 patients on antiplatelet therapy with stroke, 116 (60%) had poorly controlled risk factors. Conclusions: This study suggests that the use of antiplatelet therapy, regardless of which agent, for secondary stroke prevention may not be important or beneficial in the absence of optimal treatable cerebrovascular risk factor control. Further studies are needed to support this finding including further analysis of our data to assess risk factor control in those patients on antiplatelet therapy who did not suffer a second stroke during the period of surveillance

Antiplatelet Agents

2018 ◽  
Author(s):  
Eelco F. M. Wijdicks ◽  
Sarah L. Clark
Keyword(s):  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Endovascular Procedures ◽  
Dual Antiplatelet Therapy ◽  
Antiplatelet Agents ◽  
Mechanisms Of Action ◽  
Secondary Stroke Prevention ◽  
Vascular Medicine ◽  
Optimal Duration ◽  
Pharmacologic Management

Antiplatelet agents are commonly used in vascular medicine and cardiology, but also in the pharmacologic management of patients with ischemic stroke. Aspirin alone remains the mainstay of therapy for secondary stroke prevention. Several landmark studies for the optimal duration and dose of antiplatelet therapy in stroke prevention are discussed. Dual antiplatelet therapy is needed after carotid artery stenting. Situations where antiplatelet agents also come into play are endovascular procedures associated with procedure-related thrombi. Antiplatelet agents have different mechanisms of action, and each will be discussed. Testing of platelet function and the issue of antiplatelet resistance and discontinuation of antiplatelet agents before procedures will be discussed in this Chapter.

scholarly journals Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications?

Medicina ◽  
2021 ◽  
Vol 57 (4) ◽  
pp. 357
Author(s):  
Gabriele Savioli ◽  
Iride Francesca Ceresa ◽  
Sabino Luzzi ◽  
Alice Giotta Lucifero ◽  
Maria Serena Pioli Di Marco ◽  
...  
Keyword(s):  
Risk Factor ◽  
Antiplatelet Therapy ◽  
Head Trauma ◽  
Clinical Condition ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Control Group ◽  
Risk Of Bleeding ◽  
Level Ii ◽  
Single Center Study

Background and objectives: In patients who receive antiplatelet therapy (APT), the bleeding risk profile after mild head trauma (MHT) still needs clarification. Some studies have demonstrated an association with bleeding risk, whereas others have not. We studied the population of our level II emergency department (ED) trauma center to determine the risk of bleeding in patients receiving APT and whether bleeding results not from antiplatelet agents but rather from age. We assessed the bleeding risk, the incidence of intracranial hemorrhage (ICH) that necessitated hospitalization for observation, the need for cranial neurosurgery, the severity of the patient’s condition at discharge, and the frequency of ED revisits for head trauma in patients receiving APT. Materials and Methods: This retrospective single-center study included 483 patients receiving APT who were in the ED for MHT in 2019. The control group consisted of 1443 patients in the ED with MHT over the same period who were not receiving APT or anticoagulant therapy. Our ED diagnostic therapeutic protocol mandates both triage and the medical examination to identify patients with MHT who are taking any anticoagulant or APT. Results: APT was not significantly associated with bleeding risk (p > 0.05); as a risk factor, age was significantly associated with the risk of bleeding, even after adjustment for therapy. Patients receiving APT had a greater need of surgery (1.2% vs. 0.4%; p < 0.0001) and a higher rate of hospitalization (52.9% vs. 37.4%; p < 0.0001), and their clinical condition was more severe (evaluated according to the exit code value on a one-dimensional quantitative five-point numerical scale) at the time of discharge (p = 0.013). The frequency of ED revisits due to head trauma did not differ between the two groups. Conclusions: The risk of bleeding in patients receiving APT who had MHT was no higher than that in the control group. However, the clinical condition of patients receiving APT, including hospital admission for ICH monitoring and cranial neurosurgical interventions, was more severe.

Antiplatelet Therapy as a Risk Factor for Microbleeds in Intracerebral Hemorrhage Patients: Analysis Using Specific Antiplatelet Agents

2013 ◽  
Vol 22 (6) ◽  
pp. 834-840 ◽  
Author(s):  
Hiromitsu Naka ◽  
Eiichi Nomura ◽  
Jyuri Kitamura ◽  
Eiji Imamura ◽  
Shinichi Wakabayashi ◽  
...  
Keyword(s):  
Risk Factor ◽  
Intracerebral Hemorrhage ◽  
Antiplatelet Therapy ◽  
Antiplatelet Agents

Abstract 159: Trends in Dual Antiplatelet Therapy Prescription Patterns for Secondary Prevention in Patients With Noncardioembolic Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ying Xian ◽  
Peter Shrader ◽  
Eric Smith ◽  
Gregg C Fonarow ◽  
Deepak L Bhatt ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Patient Characteristics ◽  
Minor Stroke ◽  
Secondary Stroke Prevention ◽  
Class Iii ◽  
Prescription Patterns ◽  
Class Iib ◽  
Over Time

Background: The recommendations for dual antiplatelet (DAPT aspirin + clopidogrel) for secondary stroke prevention has evolved over time. Following the publication of CHANCE trial (07/2013), the AHA/ASA updated the DAPT recommendations from Class III harm (10/2010) for patient with noncardioembolic ischemic stroke, to Class IIb benefit ≥ risk (02/2014), and Class IIa benefit >> risk (03/2018) for a subgroup of patients with minor stroke (NIHSS≤3). Subsequent to the last guideline update, the POINT trial (05/2018) provided further support for the effectiveness of DAPT. Methods: We evaluated antiplatelet prescription patterns of 1,024,074 noncardioembolic ischemic stroke survivors (median age 65 years and 46% women) eligible for antiplatelet therapy (no contraindications) and discharged from the Get With The Guidelines-Stroke Hospitals between Q1 2011 and Q1 2019. Results: Baseline patient characteristics were similar within the four periods: pre-CHANCE (01/2011-07/2013), pre-2014 guideline update (08/2013-02/2014), pre-POINT/2018 guideline update (03/2014-05/2018), and post-POINT (06/2018-03/2019). Use of DAPT gradually increased from 16.7% in the pre-CHANCE period, to 19.4% pre-2014 guideline update, 23.3% pre-POINT/2018 guideline update, and 29.8% post-POINT period (p<0.001, Figure). Yet increase in DAPT use was observed over time for individuals with NIHSS≤3 (17.1%, 19.9%, 24.1%, and 31.4%, p<0.001) and those with NIHSS>3 (18.7%, 22.8%, 28.3%, and 28.3%, p<0.001). Conclusions: A sustained increase in DAPT use for secondary stroke prevention was observed after publication of pivotal trials and AHA guideline updates. While recommended for minor strokes or TIA only, such increase was also observed in ischemic stroke patients with NIHSS>3, where the risk-benefit ratio of DAPT remains to be established.

scholarly journals Antithrombotic Therapy in Myocardial Infarction: Historic Perils and Current Challenges—A 70-Year Journey

2020 ◽  
Vol 120 (10) ◽  
pp. 1352-1356
Author(s):  
Dion Stub ◽  
Himawan Fernando ◽  
James D. McFadyen ◽  
Jathushan Palasubramaniam ◽  
James Shaw ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Antiplatelet Therapy ◽  
Antithrombotic Therapy ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Dual Pathway ◽  
Pathway Inhibition ◽  
Direct Acting

AbstractThere have been numerous and intriguing advancements in antithrombotic therapy for myocardial infarction since it was described in the earliest issues of Thrombosis and Haemostasis. In this article, we revisit historical breakthroughs and describe the four most challenging contemporary themes relating to antithrombotic therapy in myocardial infarction. In all four, the challenge is to find the best balance of reducing specific levels of ischaemic risks without increasing bleeding risk. The first is the question of the optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). This includes discussion of monotherapy after a period of DAPT. The second relates to the role of genotype and phenotype-guided individualisation of antiplatelet therapy. There is emerging evidence for a role of pheno/genotyping in identifying individuals at high risk for recurrent ischaemic events or in guiding the timing of cardiac surgery for patients on DAPT. The third addresses the increasing evidence for dual pathway inhibition, for example, with rivaroxaban in addition to aspirin in patients where high ischaemic and low bleeding risk is demonstrated. Finally the fourth highlights the challenge of the most appropriate combination of antiplatelet and anticoagulation therapy for patients with known atrial fibrillation after PCI. In most individuals, oral P2Y12 inhibitor therapy combined with a direct acting oral anticoagulant appears to be the best strategy based on the available evidence. Overall, the progress in antithrombotic therapy achieved over the last seven decades is remarkable, however, there are important issues to address and progress still to be made.

Antiplatelet therapy in secondary stroke prevention

2000 ◽  
Vol 2 (2) ◽  
pp. 104-109 ◽  
Author(s):  
Bradford B. Worrall ◽  
Karen C. Johnston
Keyword(s):  
Antiplatelet Therapy ◽  
Stroke Prevention ◽  
Secondary Stroke Prevention

Mechanisms of platelet activation: Need for new strategies to protect against platelet-mediated atherothrombosis

2009 ◽  
Vol 102 (08) ◽  
pp. 248-257 ◽  
Author(s):  
Lisa Jennings
Keyword(s):  
Antiplatelet Therapy ◽  
Platelet Activation ◽  
Platelet Reactivity ◽  
Thrombus Formation ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Adenosine Diphosphate ◽  
Adp Receptor ◽  
Activation Pathways ◽  
New Strategies

SummaryPlatelets are central mediators of haemostasis at sites of vascular injury, but they also mediate pathologic thrombosis. Activated platelets stimulate thrombus formation in response to rupture of an atherosclerotic plaque or endothelial cell erosion, promoting atherothrombotic disease. They also interact with endothelial cells and leukocytes to promote inflammation, which contributes to atherosclerosis. Multiple pathways contribute to platelet activation, and current oral antiplatelet therapy with aspirin and a P2Y12 adenosine diphosphate (ADP) receptor antagonist target the thromboxane A2 and ADP pathways, respectively. Both can diminish activation by other factors, but the extent of their effects depends upon the agonist, agonist strength, and platelet reactivity status. Although these agents have demonstrated significant clinical benefit, residual morbidity and mortality remain high. Neither agent is effective in inhibiting thrombin, the most potent platelet activator. This lack of comprehensive inhibition of platelet function allows continued thrombus formation and exposes patients to risk for recurrent thrombotic events. Moreover, bleeding risk is a substantial limitation of antiplatelet therapy, because these agents target platelet activation pathways critical for both protective haemostasis and pathologic thrombosis. Novel antiplatelet therapies that provide more complete inhibition of platelet activation without increasing bleeding risk could considerably decrease residual risk for ischemic events. Inhibition of the protease-activated receptor (PAR)-1 platelet activation pathway stimulated by thrombin is a novel, emerging approach to achieve more comprehensive inhibition of platelet activation when used in combination with current oral antiplatelet agents. PAR-1 inhibition is not expected to increase bleeding risk, as this pathway does not interfere with haemostasis.

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