Abstract
Stroke is a leading cause of death and disability. Although advances are being made in the treatment of acute ischemic stroke, its prevention is equally as important. Identification and management of risk factors are essential. Medical therapy is also helpful in the secondary prevention of ischemic stroke. There are currently four plateletantiaggregating agents used to prevent ischemic stroke: aspirin, aspirin plus dipyridamole, clopidogrel, and ticlopidine. The relevant studies proving their efficacy are noted, as are some of their similarities and differences. The use of warfarin is also discussed.
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References and Recommended Reading
American Heart Association. Stroke facts. Available at: http://www.americanheart.org/Heart_and_Stroke_A_Z_Guide/ strokes.html. Accessed June 1, 2000.
Mohr JP, Caplan LR, Melski JW, et al.: The Harvard Cooperative Stroke Registry: a prospective registry. Neurology 1978, 28:754–762.
Furlan A, Higashida R, Wechsler L, et al.: Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. JAMA 1999, 282:2003–2011. The first large, randomized, controlled trial to show the benefit of intra-arterial pro-urokinase in middle cerebral artery thrombosis.
Sherman DG, Atkinson RP, Chippendale T, et al.: Intravenous ancrod for treatment of acute ischemic stroke. The STAT study: a randomized controlled trial. JAMA 2000, 283:2395–2403. A large, randomized, double-blind, placebo-controlled trial showing that ancrod, a defibrinogenating agent, had a favorable benefit-risk profile for patients with acute ischemic stroke.
Fuster V, Dyken ML, Vokonas PS, et al.: Aspirin as a therapeutic agent in cardiovascular disease. In American Heart Association Scientific Statement American Heart Association, Dallas 1993:659–675.
Antiplatelet Trialists’ Collaboration: Collaborative overview of randomised trials of antiplatelet therapy-I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ 1994, 308:81–106.
Kretschmer G, Pratschner T, Prager M, et al.: Antiplatelet treatment prolongs survival after carotid bifurcation endarterectomy. Analysis of the clinical series followed by a controlled trial. Ann Surg 1990, 211:317–322.
Hobson RW, Krupski WC, Weiss DG: Influence of aspirin in the management of asymptomatic carotid artery stenosis. VA Cooperative Study Group on Asymptomatic Carotid Stenosis. J Vasc Surg 1993, 17:257–263.
Dyken ML, Barnett HJ, Easton JD, et al.: Low-dose aspirin and stroke. “It ain’t necessarily so”. Stroke 1992, 23:1395–1399.
Taylor DW, Barnett HJ, Haynes RB, et al.: Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomised controlled trial. ASA and Carotid Endarterectomy (ACE) Trial Collaborators. Lancet 1999, 353:2179–2184.
Federal Register 1998, 63:56802–56819.
Gent M, Blakely JA, Easton JD, et al.: The Canadian American Ticlopidine Study (CATS) in thromboembolic stroke. Lancet 1989, 1:1215–1220.
Hass WK, Easton JD, Adams HP, Jr, et al.: A randomized trial comparing ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients. Ticlopidine Aspirin Stroke Study Group. N Engl J Med 1989, 321:501–517.
Wysowksi DK, Bacsanyi J: Blood dycrasias and hematologic reactions in ticlopidine users [letter]. JAMA 1996, 276:952.
Bennett CL, Connors JM, Carwile JM, et al.: Thrombotic thromocytopenic purpura associated with clopidogrel. N Engl J Med 2000, 342:1773–1777. An important reference reporting the association of clopidogrel with thrombotic thromocytopenic purpura. Clopidogrel had largely replaced ticlopidine in clinical practice because of its side effect profile. The clinical characteristics of the 11 patients are well documented.
CAPRIE Steering Committee: A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996, 348:1329–1339.
Diener HC, Cunha L, Forbes C, et al.: European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996, 143:1–13.
Adams HP, Bogousslavsky J, Barnathan E, et al.: Preliminary safety report of a randomized, double-blind, dose-escalation trial of abciximab in acute ischemic stroke [abstract]. Cerebrovasc Dis 1999, 9(suppl 1):1–128.
The Boston Area Anticoagulation Trial for Atrial Fibrillation Investigators. The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med 1990, 323:1505–1511.
Connolly SJ, Laupacis A, Gent M, et al.: Canadian Atrial Fibrillation Anticoagulation (CAFA) Study. J Am Coll Cardiol 1991, 18:349–355.
EAFT (European Atrial Fibrillation Trial) Study Group: Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke. Lancet 1993, 342:1255–1262.
Ezekowitz MD, Bridgers SL, James KE, et al.: Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators. N Engl J Med 1992, 327:1406–1412.
Stroke Prevention in Atrial Fibrillation Study. Final results. Circulation 1991, 84:527–539.
The Stroke Prevention in Atrial Fibrillation Investigators: Predictors of thromboembolism in atrial fibrillation: I. Clinical features of patients at risk. Ann Intern Med 1992, 116:1–5.
Atrial Fibrillation Investigators: Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994, 154:1449–1457.
Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation. Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet 1996, 348:633–638.
Chimowitz MI, Kokkinos J, Strong J, et al.: The Warfarin-Aspirin Symptomatic Intracranial Disease Study. Neurology 1995, 45:1488–1493.
Gorelick PB, Sacco RL, Smith DB, et al.: Prevention of a first stroke: a review of guidelines and a multidisciplinary consensus statement from the National Stroke Association. JAMA 1999, 28:1112–1120.
Collins R, Peto R, MacMahon S, et al.: Blood pressure, stroke, and coronary heart disease. Part 2, Short-term reductions in blood pressure: overview of randomised drug trials in their epidemiological context. Lancet 1990, 335:827–838.
SHEP Cooperative Research Group: Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA 1991, 265:3255–3264.
Yusuf S, Sleight P, Pogue J, et al.: Effects of an angiotensinconverting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000, 342:143–153. The HOPE study showed that ramipril, an angiotensin-converting enzyme inhibitor, reduced the risk of myocardial infarction, stroke, or cardiovascular death over placebo in patients with known cardiovascular disease.
Atkins D, Psaty BM, Koepsell TD, et al.: Cholesterol reduction and the risk for stroke in men. A meta-analysis of randomized, controlled trials. Ann Intern Med 1993, 119:136–145.
Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994, 344:1383–1389.
Sacks FM, Pfeffer MA, Moye LA, et al.: The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol and Recurrent Events Trial investigators. N Engl J Med 1996, 335:1001–1009.
The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group: Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998, 339:1349–1357.
Plehn JF, Davis BR, Sacks FM, et al.: Reduction of stroke incidence after myocardial infarction with pravastatin: the Cholesterol and Recurrent Events (CARE) study. The Care Investigators. Circulation 1999, 99:216–223. This large, randomized, placebo-controlled study showed that pravastatin significantly reduced stroke incidence after myocardial infarction in patients with average serum cholesterol levels and high concurrent use of antiplatelet therapy.
Blauw GJ, Lagaay AM, Smelt AH, et al.: Stroke, statins, and cholesterol. A meta-analysis of randomized, placebocontrolled, double-blind trials with HMG-CoA reductase inhibitors. Stroke 1997, 28:946–950.
Crouse JR, Byington RP, Hoen HM, et al.: Reductase inhibitor monotherapy and stroke prevention. Arch Intern Med 1997, 157:1305–1310.
Hess DC, Demchuk AM, Brass LM, et al.: HMG-CoA reductase inhibitors (statins): a promising approach to stroke prevention. Neurology 2000, 54:790–796. A thorough review of the statins and their use in stroke prevention.
Delanty N, Vaughan CJ: Vascular effects of statins in stroke. Stroke 1997, 28:2315–2320.
Summary of the second report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA 1993, 269:3015–3023.
Welch GN, Loscalzo J: Homocysteine and atherothrombosis. N Engl J Med 1998, 338:1042–1050. A review of homocysteine including its metabolism and causes, pathophysiologic mechanisms, and treatment of hyperhomocyst(e)inemia.
Stein JH, McBride PE: Hyperhomocysteinemia and atherosclerotic vascular disease: pathophysiology, screening, and treatment. Arch Intern Med 1998, 158:1301–1306.
Perry IJ, Refsum H, Morris RW, et al.: Prospective study of serum total homocysteine concentration and risk of stroke in middle-aged British men. Lancet 1995, 346:1395–1398.
Bots ML, Launer LJ, Lindemans J, et al.: Homocysteine and short-term risk of myocardial infarction and stroke in the elderly: the Rotterdam Study. Arch Intern Med 1999, 159:38–44.
Eikelboom JW, Hankey GJ, Anand SS, et al.: Association between high homocyst(e)ine and ischemic stroke due to large- and small-artery disease but not other etiologic subtypes of ischemic stroke. Stroke 2000, 31:1069–1075.
Albers GW, Easton JD, Sacco RL, et al.: Antithrombotic and thrombolytic therapy of ischemic stroke. Chest 1998, 114(suppl):683–698.
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Fleck, J.D., Biller, J. Choices in medical management for prevention of acute ischemic stroke. Curr Neurol Neurosci Rep 1, 33–38 (2001). https://doi.org/10.1007/s11910-001-0075-x
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DOI: https://doi.org/10.1007/s11910-001-0075-x