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Open Access 01-12-2015 | Research article

Comparison of antiplatelet regimens in secondary stroke prevention: a nationwide cohort study

Authors: Christine Benn Christiansen, Jannik Pallisgaard, Thomas Alexander Gerds, Jonas Bjerring Olesen, Mads Emil Jørgensen, Anna Karin Numé, Nicholas Carlson, Søren Lund Kristensen, Gunnar Gislason, Christian Torp-Pedersen

Published in: BMC Neurology | Issue 1/2015

Abstract

Background

In patients with ischemic stroke of non-cardioembolic origin, acetylsalicylic acid, clopidogrel, or a combination of acetylsalicylic acid and dipyridamole are recommended for the prevention of a recurrent stroke. The purpose of this study was to examine the risk of bleeding or recurrent stroke associated with these three treatments.

Methods

Patients who were discharged with first-time ischemic stroke from 2007–2010, with no history of atrial fibrillation were identified from Danish nationwide registries. Hazard ratios (HRs) and 1-year risks of recurrent ischemic stroke and bleeding were calculated for each antiplatelet regimen.

Results

Among patients discharged after first-time ischemic stroke, 3043 patients were treated with acetylsalicylic acid, 12,295 with a combination of acetylsalicylic acid and dipyridamole, and 3885 with clopidogrel. Adjusted HRs for clopidogrel versus the combination of acetylsalicylic acid and dipyridamole were 1.02 (95 % confidence interval [CI]: 0.89–1.17) for ischemic stroke and 1.06 (95 % CI: 0.83–1.35) for bleeding. Adjusted HRs for acetylsalicylic acid versus the combination of acetylsalicylic acid and dipyridamole were 1.48 (95 % CI: 1.31–1.67) for stroke and 1.47 (95 % CI: 1.18–1.82) for bleeding. Clopidogrel versus acetylsalicylic acid yielded HRs of 0.69 (95 % CI: 0.59–0.81) and 0.72 (95 % CI: 0.55–0.96) for stroke and bleeding, respectively. The 1-year predicted risks associated with acetylsalicylic acid, the combination of acetylsalicylic acid and dipyridamole, and clopidogrel were 11.1 (95 % CI: 10.2–12.2), 7.7 (95 % CI: 7.3–8.3), and 8.0 (95 % CI: 6.9–8.7) for ischemic stroke, respectively; while, the risks for bleeding were 3.4 (95 % CI: 2.8–3.9), 2.4 (95 % CI: 2.1–2.7), and 2.4 (95 % CI: 1.9–2.9), respectively.

Conclusion

Clopidogrel and the combination of acetylsalicylic acid and dipyridamole were associated with similar risks for recurrent ischemic stroke and bleeding; whereas acetylsalicylic acid was associated with higher risks for both ischemic stroke and bleeding. The latter finding may partially be explained by selection bias.

Furie KL, Kasner SE, Adams RJ, Albers GW, Bush RL, Fagan SC, et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the American heart Association/American Stroke Association. Stroke. 2011;42(1):227–76. doi:10.1161/STR.0b013e3181f7d043.CrossRefPubMed

Markus HS, Khan U, Birns J, Evans A, Kalra L, Rudd AG, et al. Differences in stroke subtypes between black and white patients with stroke: the South London Ethnicity and Stroke Study. Circulation. 2007;116(19):2157–64. doi:10.1161/CIRCULATIONAHA.107.699785.CrossRefPubMed

Troster S, Schuster HP, Bodmann KF. Atrial fibrillation in patients of a medical clinic--a marker for multi-morbidity and unfavorable prognosis. Med Klin. 1991;86(7):338–43.

European Stroke Organisation Executive C, Committee ESOW. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis. 2008;25(5):457–507. doi:10.1159/000131083.CrossRef

Halkes PH, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial. Lancet. 2006;367(9523):1665–73. doi:10.1016/S0140-6736(06)68734-5.CrossRefPubMed

Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci. 1996;143(1–2):1–13.CrossRefPubMed

CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet. 1996;348(9038):1329–39.CrossRef

Sacco RL, Diener HC, Yusuf S, Cotton D, Ounpuu S, Lawton WA, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med. 2008;359(12):1238–51. doi:10.1056/NEJMoa0805002.CrossRefPubMedPubMedCentral

Kent DM, Thaler DE. Stroke prevention--insights from incoherence. N Engl J Med. 2008;359(12):1287–9. doi:10.1056/NEJMe0806806.CrossRefPubMed

10.

Lynge E, Sandegaard JL, Rebolj M. The Danish national patient register. Scand J Public Health. 2011;39(7 Suppl):30–3. doi:10.1177/1403494811401482.CrossRefPubMed

11.

Kildemoes HW, Sorensen HT, Hallas J. The Danish national prescription registry. Scand J Public Health. 2011;39(7 Suppl):38–41. doi:10.1177/1403494810394717.CrossRefPubMed

12.

Gaist D, Sorensen HT, Hallas J. The Danish prescription registries. Dan Med Bull. 1997;44(4):445–8.PubMed

13.

Helweg-Larsen K. The Danish register of causes of death. Scand J Public Health. 2011;39(7 Suppl):26–9. doi:10.1177/1403494811399958.CrossRefPubMed

14.

Ekholm O, Hesse U, Davidsen M, Kjoller M. The study design and characteristics of the Danish national health interview surveys. Scand J Public Health. 2009;37(7):758–65. doi:10.1177/1403494809341095.CrossRefPubMed

15.

Olesen JB, Lip GY, Kamper AL, Hommel K, Kober L, Lane DA, et al. Stroke and bleeding in atrial fibrillation with chronic kidney disease. N Engl J Med. 2012;367(7):625–35. doi:10.1056/NEJMoa1105594.CrossRefPubMed

16.

Olesen JB, Lip GY, Hansen ML, Hansen PR, Tolstrup JS, Lindhardsen J, et al. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ. 2011;342:d124. doi:10.1136/bmj.d124.CrossRefPubMedPubMedCentral

17.

Torben Martinussen THS. Dynamic regression models for survival data. New York: Springer; 2006.

18.

Krarup LH, Boysen G, Janjua H, Prescott E, Truelsen T. Validity of stroke diagnoses in a national register of patients. Neuroepidemiology. 2007;28(3):150–4. doi:10.1159/000102143.CrossRefPubMed

Title: Comparison of antiplatelet regimens in secondary stroke prevention: a nationwide cohort study
Authors: Christine Benn Christiansen
Jannik Pallisgaard
Thomas Alexander Gerds
Jonas Bjerring Olesen
Mads Emil Jørgensen
Anna Karin Numé
Nicholas Carlson
Søren Lund Kristensen
Gunnar Gislason
Christian Torp-Pedersen
Publication date: 01-12-2015
Publisher: BioMed Central
Published in: BMC Neurology / Issue 1/2015
Electronic ISSN: 1471-2377
DOI: https://doi.org/10.1186/s12883-015-0480-4

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Comparison of antiplatelet regimens in secondary stroke prevention: a nationwide cohort study

Abstract

Background

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

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