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[Prevention of cerebral ischemia: anti-platelet agents]
1Service de neurologie et pathologie neurovasculaire, Centre Hospitalier et Universitaire de Lille. dleys@chru-lille.fr
Insights
Antiplatelet agents are crucial for preventing cerebral ischemia. In secondary prevention, clopidogrel, ticlopidine, and aspirin-dipyridamole combinations offer the highest risk reduction for atherosclerotic ischemic stroke.
Area of Science:
- Neurology
- Cardiology
- Pharmacology
Context:
- Cerebral ischemia poses a significant health risk, necessitating effective preventive strategies.
- Optimal management of stroke risk factors and carotid surgery are important, but antiplatelet agents are central to preventing cerebral ischemia.
Purpose:
- To review the role of antiplatelet agents in preventing cerebral ischemia based on available literature.
- To evaluate the efficacy of various antiplatelet agents in primary and secondary stroke prevention.
Summary:
- In primary prevention, aspirin is beneficial for specific patient groups, including those with non-valvular atrial fibrillation or high atherosclerosis risk.
- For secondary prevention of atherosclerotic ischemic stroke, aspirin, ticlopidine, clopidogrel, and dipyridamole are effective, with clopidogrel, ticlopidine, and aspirin-dipyridamole showing superior risk reduction.
- Aspirin is generally recommended for other causes of cerebral ischemia, with exceptions for high-risk cardiopathies where anticoagulation is feasible.
Impact:
- Highlights the established benefits of antiplatelet agents in secondary stroke prevention.
- Identifies areas for future research, including efficacy in lacunar infarcts, adherence to guidelines, and the role of novel antiplatelet agents.
- Provides evidence-based recommendations for antiplatelet therapy in stroke prevention.
Abstract:
Besides the optimal management of risk factors for stroke and carotid surgery, antiplatelet agents are the cornerstone for prevention of cerebral ischaemia. The aim of this overview is to determine their role in the prevention of cerebral ischaemia, from available literature. In primary prevention, the benefit of aspirin has been established only for patients with non-valvular atrial fibrillation and a low risk of cardioembolism, or as an alternative choice of warfarin, and in subjects at high risk of atherosclerosis. In secondary prevention, antiplatelet agents are effective to reduce the risk in patients with ischaemic stroke due to atherosclerosis: aspirin (50 to 1300 mg), ticlopidine (500 mg), clopidogrel (75 mg) and dipyridamole (400 mg) are effective, but the higher levels of risk reduction are obtained with clopidogrel, ticlopidine and the association aspirin--dipyridamole. Aspirin is recommended in most other causes of cerebral ischaemia, except in high risk cardiopathies when anticoagulation is possible. Other domains should still be explored: are antiplatelet agents also effective to reduce the risk of cerebral ischaemia in patients with other causes, especially lipohyalinosis of the deep perforators leading to lacunar infarcts? In daily practice, does prescription follow recommendations? Will it be possible to reproduce the results of the European Stroke Prevention Study (ESPS)2? Are antiplatelet agents other than aspirin effective in non-valvular atrial fibrillation? Are other associations of antiplatelet agents more effective than these agents alone? Finally, what will be the role of new antiplatelet agents in the future?