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Anticoagulants for preventing recurrence following ischaemic stroke or transient ischaemic attack
M Liu1, C Counsell, P Sandercock
1Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh, UK, EH4 2XU. pags@skull.dcn.ed.ac.uk
Insights
Long-term anticoagulant therapy offers no clear benefit for preventing recurrent vascular events after non-embolic ischemic stroke or transient ischemic attack. This treatment significantly increases the risk of fatal bleeding, outweighing potential advantages.
Area of Science:
- Neurology
- Vascular Medicine
- Clinical Trials
Background:
- First-time stroke is often followed by recurrent, potentially fatal vascular events, including myocardial infarction and subsequent strokes.
- Non-embolic ischemic stroke and transient ischemic attack (TIA) represent significant public health concerns due to their association with future vascular complications.
Purpose of the Study:
- To evaluate the efficacy and safety of prolonged anticoagulant therapy in patients who have experienced a presumed non-embolic ischemic stroke or TIA.
- To determine if anticoagulant treatment reduces the risk of subsequent vascular events and mortality in this patient population.
Main Methods:
- Systematic review and meta-analysis of randomized and quasi-randomized controlled trials.
- Inclusion criteria focused on trials comparing anticoagulant therapy (≥1 month) with control in patients with previous non-embolic ischemic stroke or TIA.
- Data extraction and quality assessment were performed independently by two reviewers.
Main Results:
- Nine trials involving 1214 patients were analyzed; all trials were of poor quality and predated modern diagnostic and monitoring techniques.
- Anticoagulant therapy did not significantly reduce the odds of death or dependency, recurrent stroke, or death from any or vascular causes.
- A significant increase in fatal intracranial hemorrhage (OR 2.54) and major extracranial hemorrhage (OR 4.87) was observed, translating to 11 and 25 additional major bleeds per 1000 patients annually, respectively.
Conclusions:
- Prolonged anticoagulant therapy shows no clear benefit for individuals with non-embolic ischemic stroke or TIA.
- The use of anticoagulant therapy in this context is associated with a substantial and significant increase in the risk of serious bleeding events.
Background:
After a first stroke, further vascular events (especially myocardial infarction and recurrent stroke) are common and often fatal.
Objectives:
The objective of this review was to assess the effect of prolonged anticoagulant therapy following presumed non-embolic ischaemic stroke or transient ischaemic attack.
Search Strategy:
We searched the Cochrane Stroke Group trials register. We contacted companies marketing anticoagulant agents.
Selection Criteria:
Randomised and quasi-randomised trials comparing anticoagulant therapy, for at least one month, with control in people with previous non-embolic presumed ischaemic stroke or transient ischaemic attack.
Data Collection And Analysis:
Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data.
Main Results:
Nine trials involving 1214 patients were included. The quality of all trials was poor. All pre-dated routine computerised tomography scanning and use of the International Normalised Ratio to monitor anticoagulation. Anticoagulant therapy did not significantly reduce the odds of death or dependency (two trials, odds ratio 0.83, 95% confidence interval 0.52 to 1.34). Death from any cause (odds ratio 0.95, 95% confidence interval 0.72 to 1.23), and death from vascular causes (odds ratio 0.86, 95% confidence interval 0.66 to 1.13) were not significantly different between treatment and control across all nine trials. Anticoagulant therapy did not reduce the risk of recurrent stroke (odds ratio 0.79, 95% confidence interval 0.56 to 1.13). However, fatal intracranial haemorrhage increased (odds ratio 2.54, 95% confidence interval 1.19 to 5.45), as did major extracranial haemorrhage (odds ratio 4.87, 95% confidence interval 2.50 to 9.49). This means anticoagulant therapy caused 11 additional fatal intracranial haemorrhages and 25 additional major extracranial haemorrhages per year for every 1000 patients given anticoagulant therapy.
Reviewer'S Conclusions:
There appears to be no clear benefit from long-term anticoagulant therapy in people with non-embolic presumed ischaemic stroke or transient ischaemic attack. There appears to be a significant bleeding risk associated with anticoagulant therapy.