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Antithrombotic Treatment for Cervical Artery Dissection: A Systematic Review and Individual Patient Data
Josefin E Kaufmann1,2, Eric L Harshfield3, Henrik Gensicke1,2
1Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Switzerland.
Insights
Cervical artery dissection stroke prevention shows no significant difference between anticoagulants and antiplatelets. This meta-analysis found similar early recurrent event rates, highlighting the need for further research in antithrombotic therapy.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Clinical Trials
Background:
- Cervical artery dissection (CAD) is a leading cause of stroke in young adults.
- Optimal antithrombotic therapy for CAD remains unclear, lacking conclusive evidence.
Purpose of the Study:
- To conduct an individual patient data meta-analysis of randomized clinical trials (RCTs).
- To compare anticoagulants versus antiplatelets for preventing stroke after CAD.
Main Methods:
- Systematic review and meta-analysis of RCTs comparing anticoagulation and antiplatelet therapy in CAD patients.
- Data sourced from PubMed, Cochrane, Embase, and ClinicalTrials.gov up to August 2023.
- Primary outcome: composite of stroke, death, or major bleeding at 90 days.
Main Results:
- Two RCTs with 444 patients (intention-to-treat) were included.
- No statistically significant difference in the primary composite outcome between anticoagulation and antiplatelets (OR 0.33; P=0.06).
- Anticoagulation showed fewer strokes (OR 0.14; P=0.01) but more bleeding events compared to aspirin.
Conclusions:
- Individual patient data meta-analysis of 2 RCTs found no significant difference in preventing early recurrent events between anticoagulants and antiplatelets.
- Current evidence does not definitively favor one antithrombotic strategy over the other for CAD.
- Further research is warranted to establish optimal antithrombotic treatment for CAD.
Importance:
Cervical artery dissection is the most common cause of stroke in younger adults. To date, there is no conclusive evidence on which antithrombotic therapy should be used to treat patients.
Objective:
To perform an individual patient data meta-analysis of randomized clinical trials comparing anticoagulants and antiplatelets in prevention of stroke after cervical artery dissection.
Data Sources:
PubMed.gov, Cochrane database, Embase, and ClinicalTrials.gov were searched from inception to August 1, 2023.
Study Selection:
Randomized clinical trials that investigated the effectiveness and safety of antithrombotic treatment (antiplatelets vs anticoagulation) in patients with cervical artery dissection were included in the meta-analysis. The primary end point was required to include a composite of (1) any stroke, (2) death, or (3) major bleeding (extracranial or intracranial) at 90 days of follow-up.
Data Extraction/Synthesis:
Two independent investigators performed a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and inconsistencies were resolved by a principal investigator.
Main Outcomes And Measures:
The primary outcome was a composite of (1) ischemic stroke, (2) death, or (3) major bleeding (extracranial or intracranial) at 90 days of follow-up. The components of the composite outcome were also secondary outcomes. Subgroup analyses based on baseline characteristics with a putative association with the outcome were performed. Logistic regression was performed using the maximum penalized likelihood method including interaction in the subgroup analyses.
Results:
Two randomized clinical trials, Cervical Artery Dissection in Stroke Study and Cervical Artery Dissection in Stroke Study and the Biomarkers and Antithrombotic Treatment in Cervical Artery Dissection, were identified, of which all participants were eligible. A total of 444 patients were included in the intention-to-treat population and 370 patients were included in the per-protocol population. Baseline characteristics were balanced. There were fewer primary end points in those randomized to anticoagulation vs antiplatelet therapy (3 of 218 [1.4%] vs 10 of 226 [4.4%]; odds ratio [OR], 0.33 [95% CI, 0.08-1.05]; P = .06), but the finding was not statistically significant. In comparison with aspirin, anticoagulation was associated with fewer strokes (1 of 218 [0.5%] vs 10 of 226 [4.0%]; OR, 0.14 [95% CI, 0.02-0.61]; P = .01) and more bleeding events (2 vs 0).
Conclusions And Relevance:
This individual patient data meta-analysis of 2 currently available randomized clinical trial data found no significant difference between anticoagulants and antiplatelets in preventing early recurrent events.
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