Secondary stroke prevention with antithrombotic drugs

This review addresses 2 fields: secondary prevention after cerebral ischaemia of cardiac origin (CICO) and that after cerebral ischaemia of arterial origin (CIAO). The major trial after CICO is the EAFT that showed the superiority of mild oral anticoagulation (INR 2-3) over aspirin and placebo. Despite several more recent trials with ximelagatran (e.g. SPORTIF and ACTIVE-W) the current standard remains mild oral anticoagulation. After CIAO several trials tried to improve the 13% relative risk reduction achieved with aspirin. Attempts with oral anticoagulation were disappointing: high INRs were not safe (SPIRIT), low INRs not effective (WARSS) and with a mild regimen (INR 2-3) the benefits for ischaemic events were cancelled by more major bleeding. Clopidogrel tended to be modestly more effective than aspirin after stroke (CAPRIE), but its combination with aspirin appeared not to be safe (MATCH, CHARISMA). Combination of aspirin with dipyridamole, however, was safe and more effective than aspirin alone (ESPS-2, ESPRIT). Recent American and European guidelines mention both the combination of aspirin and dipyridamole and clopidogrel monotherapy for secondary prevention after cerebral ischaemia of arterial origin. The recent PRoFESS trial found no differences in the efficacy of aspirin plus dipyridamole and clopidogrel, hence there is no need for major adaptation of the guidelines.