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Antiplatelets versus anticoagulants for the treatment of cervical artery dissection: Bayesian meta-analysis
Hakan Sarikaya1, Bruno R da Costa, Ralf W Baumgartner
1Department of Neurology, University Hospital of Zurich, Zurich, Switzerland ; Department of Neurology, University Hospital of Bern, Bern, Switzerland.
Insights
Antiplatelets are more effective than anticoagulants in preventing stroke and death for patients with cervical artery dissection. Given their safety and cost benefits, antiplatelets are recommended as first-line treatment.
Area of Science:
- Neurology
- Cardiology
- Pharmacology
Background:
- Cervical artery dissection (CAD) is a significant cause of stroke in younger adults.
- Optimal medical management for CAD, particularly the choice between antiplatelets and anticoagulants, remains debated.
Purpose of the Study:
- To compare the efficacy of antiplatelet therapy versus anticoagulant therapy in reducing stroke and death in patients diagnosed with acute cervical artery dissection.
Main Methods:
- A systematic review and Bayesian meta-analysis were conducted.
- Searched MEDLINE and EMBASE databases up to November 2012, including randomized, quasi-randomized, and observational studies.
- Bayesian techniques were employed to handle scarce event data and group size imbalances.
Main Results:
- Thirty-seven studies with 1991 patients were included; no randomized trials were found.
- Primary analysis indicated a significant benefit of antiplatelets in preventing ischemic stroke, intracranial hemorrhage, or death within 3 months (RR 0.32, 95% CrI 0.12–0.63).
- Analysis of higher-quality studies showed a less pronounced advantage for antiplatelets (RR 0.73, 95% CrI 0.17–2.30).
Conclusions:
- Antiplatelets demonstrate a favorable effect in preventing adverse outcomes in cervical artery dissection.
- Considering safety, ease of use, and cost, antiplatelets are recommended as the preferred first-line treatment.
- Further adequately powered randomized trials are needed to definitively confirm these findings.
Objective:
To compare the effects of antiplatelets and anticoagulants on stroke and death in patients with acute cervical artery dissection.
Design:
Systematic review with Bayesian meta-analysis.
Data Sources:
The reviewers searched MEDLINE and EMBASE from inception to November 2012, checked reference lists, and contacted authors.
Study Selection:
Studies were eligible if they were randomised, quasi-randomised or observational comparisons of antiplatelets and anticoagulants in patients with cervical artery dissection.
Data Extraction:
Data were extracted by one reviewer and checked by another. Bayesian techniques were used to appropriately account for studies with scarce event data and imbalances in the size of comparison groups.
Data Synthesis:
Thirty-seven studies (1991 patients) were included. We found no randomised trial. The primary analysis revealed a large treatment effect in favour of antiplatelets for preventing the primary composite outcome of ischaemic stroke, intracranial haemorrhage or death within the first 3 months after treatment initiation (relative risk 0.32, 95% credibility interval 0.12 to 0.63), while the degree of between-study heterogeneity was moderate (τ(2) = 0.18). In an analysis restricted to studies of higher methodological quality, the possible advantage of antiplatelets over anticoagulants was less obvious than in the main analysis (relative risk 0.73, 95% credibility interval 0.17 to 2.30).
Conclusion:
In view of these results and the safety advantages, easier usage and lower cost of antiplatelets, we conclude that antiplatelets should be given precedence over anticoagulants as a first line treatment in patients with cervical artery dissection unless results of an adequately powered randomised trial suggest the opposite.
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