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01-11-2016 | Original Communication

Efficacy and safety of short-term dual- versus mono-antiplatelet therapy in patients with ischemic stroke or TIA: a meta-analysis of 10 randomized controlled trials

Authors: Yang Liu, Zhaoxia Fei, Wei Wang, Jingxue Fang, Meijuan Zou, Gang Cheng

Published in: Journal of Neurology | Issue 11/2016

Abstract

Stroke is still a primary disease for death and disability all over the world. The optimal antiplatelet therapy for treatment of stroke is under controversy. We performed a meta-analysis to justify whether short-term (≤1 year) dual-antiplatelet therapy (DAPT) has advantages over mono-antiplatelet therapy. We systematically searched the databases of Cochrane library, Pubmed and Embase up to July 2016. Randomized controlled trials (RCTs) comparing DAPT with mono-antiplatelet therapy were included in our meta-analysis. Totally ten trials involving 8969 patients were satisfied with our inclusion criteria. At the end of follow-up, DAPT is associated with a significant reduction in recurrent stroke [risk ratio (RR) 0.65, 95 % confidence interval (CI) 0.56–0.76, P < 0.00001] and the net clinical outcome (ischemic stroke (IS) recurrence plus major bleeding) (RR 0.67, 95 % CI 0.58–0.79, P < 0.00001). In terms of safety outcomes of major bleeding (RR 1.44, 95 % CI 0.72–2.88, P = 0.30) and intracranial hemorrhage (RR 1.29, 95 % CI 0.56–2.93, P = 0.55), DAPT has a homologous safety profile compared with mono-antiplatelet therapy. The subgroup analysis according to different races, antiplatelet combinations or initiation time produced similar outcomes as comprehensive outcomes. Given short-term treatment regimen, DAPT can be superior to mono-antiplatelet therapy in treating IS or transient ischemic attack (TIA). No matter in acute or non-acute phase of IS, short-term DAPT has more efficacy than mono-antiplatelet therapy and has equivalent safety as mono-antiplatelet therapy.

Lozano R, Naghavi M, Foreman K et al (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859):2095–2128CrossRefPubMed

Vos T, Flaxman AD, Naghavi M et al (2012) Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859):2163–2196CrossRefPubMed

Wong KS, Chen C, Ng PW et al (2007) Low-molecular-weight heparin compared with aspirin for the treatment of acute ischaemic stroke in Asian patients with large artery occlusive disease: a randomised study. Lancet Neurol 6(5):407–413CrossRefPubMed

Torbey MT, Bösel J, Rhoney DH et al (2015) Evidence-based guidelines for the management of large hemispheric infarction: a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine. Neurocrit Care 22(1):146–164CrossRefPubMed

Wu X, Zhu B, Fu L et al (2013) Prevalence, incidence, and mortality of stroke in the Chinese island populations: a systematic review. PLoS One 8(11):e78629CrossRefPubMedPubMedCentral

Krishnamurthi RV, Moran AE, Feigin VL et al (2015) Stroke prevalence, mortality and disability-adjusted life years in adults aged 20–64 years in 1990–2013: data from the global burden of disease 2013 study. Neuroepidemiology 45(3):190–202CrossRefPubMed

Coull AJ, Lovett JK, Rothwell PM et al (2004) Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ 328(7435):326CrossRefPubMedPubMedCentral

Petty GW, Brown RD Jr, Whisnant JP et al (1998) Survival and recurrence after first cerebral infarction: a population-based study in Rochester, Minnesota, 1975 through 1989. Neurology 50(1):208–216CrossRefPubMed

Sandercock PA, Counsell C, Tseng MC et al (2014) Oral antiplatelet therapy for acute ischaemic stroke. Cochrane Database Syst Rev (3):CD000029

10.

Piepoli MF, Hoes AW, Agewall S et al (2016) 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J pii:ehw106 [Epub ahead of print]

11.

Markus HS, Droste DW, Kaps M et al (2005) Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using doppler embolic signal detection: the clopidogrel and aspirin for reduction of emboli in symptomatic carotid stenosis (CARESS) Trial. Circulation 111(17):2233–2240CrossRefPubMed

12.

Bal Dit Sollier C, Crassard I, Simoneau G et al (2009) Effect of the thromboxane prostaglandin receptor antagonist terutroban on arterial thrombogenesis after repeated administration in patients treated for the prevention of ischemic stroke. Cerebrovasc Dis 28(5):505–513CrossRefPubMed

13.

Wang Y, Wang Y, Zhao X et al (2013) Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med 369(1):11–19CrossRefPubMed

14.

Wong KS, Chen C, Fu J et al (2010) Clopidogrel plus aspirin versus aspirin alone for reducing embolisation in patients with acute symptomatic cerebral or carotid artery stenosis (CLAIR study): a randomised, open-label, blinded-endpoint trial. Lancet Neurol 9(5):489–497CrossRefPubMed

15.

He F, Xia C, Zhang JH et al (2015) Clopidogrel plus aspirin versus aspirin alone for preventing early neurological deterioration in patients with acute ischemic stroke. J Clin Neurosci 22(1):83–86CrossRefPubMed

16.

Kennedy J, Hill MD, Ryckborst KJ et al (2007) Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): a randomised controlled pilot trial. Lancet Neurol 6(11):961–969CrossRefPubMed

17.

Yi X, Lin J, Wang C et al (2014) A Comparative Study of Dual versus Monoantiplatelet Therapy in Patients with Acute Large-Artery Atherosclerosis Stroke. J Stroke Cerebrovasc Dis 23(7):1975–1981

18.

Dengler R, Diener HC, Schwartz A et al (2010) Early treatment with aspirin plus extended-release dipyridamole for transient ischaemic attack or ischaemic stroke within 24 h of symptom onset (EARLY trial): a randomised, open-label, blinded-endpoint trial. Lancet Neurol 9(2):159–166CrossRefPubMed

19.

Chairangsarit P, Sithinamsuwan P, Niyasom S et al (2005) Comparison between aspirin combined with dipyridamole versus aspirin alone within 48 hours after ischemic stroke event for prevention of recurrent stroke and improvement of neurological function: a preliminary study. J Med Assoc Thai 88(Suppl 3):S148–S154PubMed

20.

Bath PM, Cotton D, Martin RH et al (2010) Effect of combined aspirin and extended-release dipyridamole versus clopidogrel on functional outcome and recurrence in acute, mild ischemic stroke PRoFESS subgroup analysis. Stroke 41(4):732–738CrossRefPubMed

21.

Ge F, Lin H, Liu Y et al (2016) Dual antiplatelet therapy after stroke or transient ischaemic attack-how long to treat? The duration of aspirin plus clopidogrel in stroke or transient ischaemic attack: a systematic review and meta-analysis. Eur J Neurol 23(6):1051–1057CrossRefPubMed

22.

Zhang Q, Wang C, Zheng M (2015) Aspirin plus clopidogrel as secondary prevention after stroke or transient ischemic attack: a systematic review and meta-analysis. Cerebrovasc Dis 39(1):13–22PubMed

23.

Wong KS, Wang Y, Leng X et al (2013) Early dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack an updated systematic review and meta-analysis. Circulation 128(15):1656–1666CrossRefPubMed

24.

Moher D, Liberati A, Tetzlaff J et al (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 339:b2535CrossRefPubMedPubMedCentral

25.

Diener HC, Bogousslavsky J, Brass LM et al (2004) MATCH investigators. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 364(9431):331–337CrossRefPubMed

26.

Benavente OR, Hart RG, McClure LA et al (2012) Effects of clopidogrel added to aspirin in patients with recent lacunar stroke. N Engl J Med 367(9):817–825CrossRefPubMed

27.

Zhou YH, Wei X, Lu J et al (2012) Effects of combined aspirin and clopidogrel therapy on cardiovascular outcomes: a systematic review and meta-analysis. PLoS One 7(2):e31642CrossRefPubMedPubMedCentral

28.

Lee M, Saver JL, Hong KS et al (2013) Risk-benefit profile of long-term dual- versus single-antiplatelet therapy among patients with ischemic stroke. Ann Intern Med 159(7):463–470CrossRefPubMed

29.

Niu PP, Guo ZN, Jin H et al (2016) Antiplatelet regimens in the long-term secondary prevention of transient ischaemic attack and ischaemic stroke: an updated network meta-analysis. BMJ Open 6(3):e009013CrossRefPubMedPubMedCentral

30.

Huang HP, Lin WH, Chen SG et al (2016) Comparative efficacy and safety of nine anti-platelet therapies for patients with ischemic stroke or transient ischemic attack: a mixed treatment comparisons. Mol Neurobiol [Epub ahead of print]

31.

Xie W, Zheng F, Zhong B et al (2015) Long-term antiplatelet mono- and dual therapies after ischemic stroke or transient ischemic attack: network meta-analysis. J Am Heart Assoc 4(8):e002259CrossRefPubMedPubMedCentral

32.

Johnston SC, Easton JD, Farrant M et al (2013) Platelet-oriented inhibition in new TIA and minor ischemic stroke (POINT) trial: rationale and design. Int J Stroke 8(6):479–483CrossRefPubMedPubMedCentral

33.

Krishnan K, Beridze M, Christensen H et al (2015) Safety and efficacy of intensive vs. guideline antiplatelet therapy in high-risk patients with recent ischemic stroke or transient ischemic attack: rationale and design of the triple antiplatelets for reducing dependency after ischaemic stroke (TARDIS) trial (ISRCTN47823388). Int J Stroke 10(7):1159–1165CrossRefPubMed

Title: Efficacy and safety of short-term dual- versus mono-antiplatelet therapy in patients with ischemic stroke or TIA: a meta-analysis of 10 randomized controlled trials
Authors: Yang Liu
Zhaoxia Fei
Wei Wang
Jingxue Fang
Meijuan Zou
Gang Cheng
Publication date: 01-11-2016
Publisher: Springer Berlin Heidelberg
Published in: Journal of Neurology / Issue 11/2016
Print ISSN: 0340-5354
Electronic ISSN: 1432-1459
DOI: https://doi.org/10.1007/s00415-016-8260-7

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Efficacy and safety of short-term dual- versus mono-antiplatelet therapy in patients with ischemic stroke or TIA: a meta-analysis of 10 randomized controlled trials

Abstract

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Abstract

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