Antithrombotics in the prevention of cerebrovascular accidents.
Part I – Significance of antiplatelet treatment

Česká verzia

Authors: J. Bultas; D. Karetová
Published in the journal: Kardiol Rev Int Med 2012, 14(3): 200-206
Category:

Summary

The prophylaxis of cerebrovascular accidents is based on three pillars – regimen, alteration of atherogenic risk factors and antithrombotic treatment. In patients treated within the secondary prevention of cardiovascular accidents, i.e. prophylaxis of atherothrombosis, primary haemostasis plays the dominant role and therefore, the therapy focuses on altering platelet functions. On the contrary, in the case of atrial fibrillation or flutter, when blood stagnation with coagulation activation comes first, anticoagulants are suitable. If both the conditions coincide, both therapy modes are conveniently combined. In the prophylaxis of vascular accidents in a patient who suffered from a cerebral accident, acetylsalicylic acid is used to alter the functions of hyperactivated thrombocytes in the first place, with clopidogrel being used as an alternative if acetylsalicylic acid cannot be administered. This alternative demonstrates a comparable effect and a comparable risk of bleeding complications. A third option is the application of a fixed combination of a small dose of acetylsalicylic acid with dipyridamole. Such treatment equals clopidogrel in terms of efficacy and safety, while being more efficient than a subtherapeutic dose of 25 mg of acetylsalicylic acid; however, it is no more efficient than the usual ASA doses (30 to 325 mg). Prospectively, the introduction of new drugs is presumed, in particular cilostazol, which is expected to be available in the Czech Republic in the coming years. Based on the results of on-going studies, the effect of new ADP receptor inhibitors, ticagrelor and prasugrel, is expected to be confirmed as well.

Keywords:
cerebrovascular accident – secondary prevention – antiplatelet therapy – acetylsalicylic acid – clopidogrel – dipyridamole – cilostazol

Zdroje

1. Cox D, Maree AO, Dooley M et al. Effect of enteric coating on antiplatelet activity of low-dose aspirin in healthy volunteers. Stroke 2006; 37: 2153–2158.

2. Charlot M, Grove EL, Hansen PR et al. Proton pump inhibitor use and risk of adverse cardiovascular events in aspirin treated patients with first time myocardial infarction: nationwide propensity score matched study. BMJ 2011; 342: d2690.

3. Baigent C, Blackwell L, Collins R et al. Antithrombotic Trialists‘ (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009; 373: 1849–1860.

4. Gubitz G, Counsell C, Sandercock P et al. Anticoagulants for acute ischaemic stroke. Cochrane Database Syst Rev 2000; (2): CD000024.

5. Costa J, Ferro JM, Matias-Guiu J et al. Triflusal for preventing serious vascular events in people at high risk. Cochrane Database Syst Rev 2005; 3: CD004296.

6. Hart RC, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 2007; 146: 857–867.

7. Connolly S, Pogue J, Hart R et al. ACTIVE Writing Group of the ACTIVE Investigators. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet 2006; 367: 1903–1912.

8. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348: 1329–1339.

9. Diener HC, Bogousslavsky J, Brass LM et al. 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 2004; 364: 331–337.

10. Bhatt DL, Fox KA, Hacke W et al. CHARISMA Investigators. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006; 354: 1706–1717.

11. 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.

12. Rocca B, Petrucci G. Variability in the responsiveness to low-dose aspirin: pharmacological and disease-related mechanisms. Thrombosis 2012; 2012: 376721.

13. Halkes PH, van Gijn J, Kappelle LJ et al. ESPRIT Study Group. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial. Lancet 2006; 367: 1665–1673.

14. Tirschwell D. Aspirin plus dipyridamole was more effective than aspirin alone for preventing vascular events after minor cerebral ischemia. ACP J Club 2006; 145: 57.

15. De Schryver EL, Algra A, van Gijn J. Dipyridamole for preventing stroke and other vascular events in patients with vascular disease. Cochrane Database Syst Rev 2007; 3: CD001820.

16. Sacco RL, Diener HC, Yusuf S et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med 2008; 359: 1238–1251.

17. Schneck MJ. Understanding the PRoFESS Study for Secondary Stroke Prevention. Curr Treat Options Cardiovasc Med 2009; 11: 221–231.

18. Matsumoto M. Cilostazol in secondary prevention of stroke: impact of the Cilostazol Stroke Prevention Study. Atheroscler Suppl 2005; 6: 33–40.

19. Shinohara Y, Katayama Y, Uchiyama S et al. Cilostazol for prevention of secondary stroke (CSPS 2): an aspirin-controlled, double-blind, randomised non-inferiority trial. Lancet Neurol 2010; 9: 959–968.

20. Huang Y, Cheng Y, Wu J et al. Cilostazol as an alternative to aspirin after ischaemic stroke: a randomised, double-blind, pilot study. Lancet Neurol 2008; 7: 494–499.

21. Lansberg MG, O’Donnell MJ, Khatri P et al. Antithrombotic and thrombolytic therapy for ischemic stroke: Antithrombotic Therapy and Prevention of Thrombosis, 9^th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl 2): e601S–e636S.

22. SPS3 Investigators. Benavente OR, Hart RG, McClure LA et al. Effects of clopidogrel added to aspirin in patients with recent lacunar stroke. N Engl J Med 2012; 367: 817–825.