Stroke is the leading cause of adult-acquired disability in most places in the world and the second-leading cause of death worldwide [ 2 — 4 ]. In the era of contemporary secondary prevention strategies patients, approximately one in seven patients will have a recurrent event within one year of their first stroke or TIA Transient Ischemic Attack [ 5 ].
Previous trials investigating the role of another antiplatelet combination, aspirin plus dipyridamole ASA-DPfound a benefit in favor of the combination over either agent alone for secondary stroke prevention [ 78 ]. Though non-significant, aspirin and plavix combination, the subset of patients randomized within seven days showed a trend towards a benefit of combination over mono antiplatelet therapy The study was terminated prematurely due to lack aspirin and plavix combination recruitment.
There was a non-significant reduction in recurrent aspirin and plavix combination in the dual antiplatelet group 7. Twelve randomized trials including subjects recurrent strokes in total were analyzed. Participants were assigned to receive single or dual antiplatelet agents within 72 hours of stroke or TIA and continued therapy for seven days—42 months. Stroke recurrence was significantly reduced in the dual vs the single antiplatelet group 3.
There was no difference with regards to overall mortality. Dual therapy was associated with a non-significant increase in major bleeding 0.
Aspirin and plavix combination nonsignificant trends from MATCH and FASTER as well as the meta-analysis data suggested that there may be a beneficial effect of dual antiplatelet therapy in the acute phase following cerebral ischemic events.
There other aspirin and plavix combination trials examining aspirin and plavix combination use of early combination antiplatelet therapy after ischemic events that may help to better clarify these issues. Further prospective trials may help to clarify if patients on dual antiplatelet therapy may benefit from reduced rates of recurrent stroke without an excess of bleeding, as well whether there is an optimal duration for length of dual antiplatelet therapy.
The preliminary results of the trial, announced in February at the International Stroke Conference, showed that the hazard ratio at 90 days for the primary endpoint of ischemic or hemorrhagic stroke was 0. For the secondary endpoint of stroke, MI, and vascular death, aspirin and plavix combination day hazard ratio was 0. There was no difference between groups with regards to incidence of hemorrhagic stroke 0.
There was a non-significant increase in minor bleeding 1. Other ongoing studies will determine if these results are replicable in other populations. Implementation of other optimal secondary prevention strategies is not standardized in China or in the CHANCE population, and post-stroke care may differ from North American standards [ 21 ].
Whether differences with regards to stroke subtype or other genetic, environmental, or undetermined factors may also affect the benefit-risk ratio of combination antiplatelet therapy in other ongoing trials aricept and bipolar illness yet to be determined. So far, more than patients are enrolled and the results are anticipated by Results are still pending.
Approximately one-quarter of ischemic strokes are aspirin and plavix combination to small vessel disease, also referred to as lacunar, or small subcortical, strokes. Intrinsic cerebral small vessel disease, based on previous pathological series, has multiple mechanisms, the commonest being lipohyalinosis, aspirin and plavix combination, which involves chronic fibrin and collagen deposition in the walls of penetrating vessels and microatheroma which can either be occlusive or embolic in and of itself or secondary to plaque rupture with subsequent thrombotic occlusion or embolization [ 22 ].
Intrinsic endothelial dysfunction has also been proposed as a possible mechanism [ 23 ]. However, classification of strokes due to small vessel disease in these trials was vaguely defined without neuroimaging confirmation in most cases [ 24 ].
In addition, the mechanism of antiplatelet therapy for stroke prevention in this stroke subtype is not completely elucidated. Primary outcomes were all recurrent stroke, secondary outcomes included acute myocardial infarction, and death vascular, non-vascular or unknownand primary safety outcome was major extracranial hemorrhage. The antiplatelet arm of the trial was double-blinded. Analyses were aspirin and plavix combination on an intention-to-treat paradigm, aspirin and plavix combination.
Over the follow-up period, 8. There was no significant difference in overall risk of recurrent stroke between the single vs dual antiplatelet groups 2. The rate of major systemic hemorrhage in the dual antiplatelet group was nearly twice that of the aspirin-only group 1. Bells palsy and vitamins was an excess of all-cause mortality in the dual antiplatelet group 77 vsHR 1.
When mortality was subdivided by cause, there was a significant increase with respect to probable vascular death HR 3. This trial, which has the largest series in the literature to date of radiologically proven small subcortical infarcts, showed no benefit for long-term use of combination antiplatelet therapy for secondary prevention of this particular stroke mechanism. The higher mortality rate in the dual antiplatelet group was unanticipated and not due to an excess of fatal hemorrhage.
The authors suggested that the difference may have been due to chance, or possibly due to a detrimental effect of combination therapy on patients with the distinct vascular risk profile of patients with cerebral small-vessel disease. Given that those at risk for death were found to have moderate bleeding [ 27 ] or were diabetic [ 28 ] with nephropathy [ 29 ], the authors posited that the SPS3 patients, who were not typical large-artery vasculopaths, may possibly have baby barns plans and specs at risk with combination antiplatelet therapy for similar reasons.
The results showed a decrease in mortality associated with dual antiplatelet therapy in short-term studies follow-up 14 days—3 months; OR 0. Combination antiplatelet therapy was associated with an increased risk of fatal hemorrhage OR 1. Of all the stroke mechanisms, atherothrombotic large-vessel disease has the highest risk of early recurrence rate after stroke or TIA [ 30 ].
Carotid endar-terectomy and stenting are superior to best medical therapy alone including antiplatelet therapy for secondary prevention for symptomatic extracranial carotid stenosis. Whether dual antiplatelet therapy confers additional protection against recurrent events for intracranial large-vessel disease is still unclear, aspirin and plavix combination. Recruitment was terminated after participants were enrolled due to an excess of stroke and death at 30 days in the stenting arm However, participants in the medical arm experienced a lower rate of recurrent stroke than in previous series of symptomatic intracranial stenosis treated with a single antiplatelet agent Whether the use of dual antiplatelet therapy contributed significantly to the aspirin and plavix combination event rate is unclear given that there was no single-platelet medical comparison group in the SAMMPRIS trial.
Thus, the role for dual antiplatelet therapy for symptomatic intracranial stenosis remains unclear. The use of microemboli aspirin and plavix combination a clinically relevant proxy to assess secondary prevention is controversial. It is unclear whether the number of detectable microemboli, aspirin and plavix combination their presence or timing, serves as a reliable harbinger of a recurrent clinical ischemic event. Patients were monitored at two and seven days for microembolic signals on transcranial Doppler.
Analysis was a modified intention-to-treat and primary outcome was the proportion of patients with microembolic signals on day two. There were no major hemorrhages overall, though there were two minor bleeding events in the dual antiplatelet group and none in the monotherapy group. Patients were assessed for microembolic signals at two and seven days after enrollment. The primary endpoint was the proportion of patients with microembolic signals on day seven, aspirin and plavix combination.
Dramamine and valium was by intention-to-treat. There was a significant reduction proportion of patients with detectable microemboli on day seven There was a nonsignificant trend towards a benefit on day 2, aspirin and plavix combination.
There was also a significant decrease in number of microemboli per hour on days two and seven. There were no major bleeding events in either group, though there were two minor bleeding events in the dual antiplatelet group and one in the monotherapy group. There is a suggestion that optimized secondary prevention measures are beneficial in secondary stroke prevention for symptomatic intracranial stenosis, and there is evidence that microembolic signals may be reduced with dual antiplatelet therapy.
Still, the clinical benefits of dual over single antiplatelet therapy for secondary prevention of symptomatic large artery disease have yet to be definitely demonstrated in randomized trials. There was an overall reduction of combined vascular events 6. On the other hand, dual antiplatelet therapy had a significantly increased incidence of major bleeding 2. The trial was halted after 1. There was no significant different in major bleeding 2, aspirin and plavix combination.
Unless all anticoagulant options are untenable, there is no compelling reason to treat patients with an antiplatelet agent for secondary prevention of cardioembolic stroke. There is a marginal benefit of dual antiplatelet therapy over aspirin monotherapy for aspirin and plavix combination indication, though it is nearly eclipsed by the corresponding increased risk of bleeding.
Aortic arch atheroma with plaque thickness greater than 4—5 mm has been associated with increased risk of stroke. In one meta-analysis the odds of stroke in a patients with severe arch atheroma compared with without diabetes and valve surgery 3. Additional risk factors in the context of thick aortic plaque include plaque ulceration, non-calcified plaque, aspirin and plavix combination, and plaque with mobile components [ 40 ].
It is unclear as to which antithrombotic therapy is best for stroke prevention in this context. A definitive indication for long-term dual antiplatelet therapy for secondary stroke prevention has not yet been demonstrated in randomized trials. However, the preliminary results of the CHANCE trial suggest that use of dual antiplatelet therapy in the acute post-ischemic period for a limited duration may be of benefit. Whether patients with symptomatic intracranial disease may benefit from dual antiplatelet therapy over monotherapy and for what period of time in addition to medical and lifestyle optimization will need to be addressed in future randomized trials.
Though antiplatelet agents are the mainstay of antithrombotic therapy for secondary prevention of noncardioembolic cerebral ischemic events, the efficacy of combination effexor xr 75 mg and ocd and clopidogrel has yet to be clarified by clinical trials. Other ongoing trials, which are also investigating the role of short-term combination antiplatelet therapy initiated immediately after minor stroke and TIA, will determine if these findings will be replicated.
Benavente is a board member for Otsuka and Bayer. National Center for Biotechnology InformationU. Curr Treat Options Cardiovasc Med. Author manuscript; available in PMC Apr 8. See other articles in PMC that cite the published article. Introduction Stroke is the leading cause of adult-acquired disability in most places in the world and the second-leading cause of death worldwide [ 2 — 4 ]. Open in a separate window. Combination compare norethindrone acetate and norgestrel therapy for cerebral small vessel disease Approximately one-quarter of ischemic strokes are due to small vessel disease, also referred to as lacunar, or small subcortical, strokes.
Combination antiplatelet therapy for large-vessel disease Of all the stroke mechanisms, atherothrombotic large-vessel disease has the highest risk of early recurrence rate after stroke or TIA [ 30 ]. Combination antiplatelet therapy for aortic arch atheroma Aortic arch atheroma with plaque thickness greater than 4—5 mm has been associated with increased risk of stroke.
Conclusions A definitive indication for long-term dual antiplatelet therapy for difference between plant and animal hormones stroke prevention has not yet been demonstrated in randomized trials. Footnotes Conflict of Interest Dr. References and Recommended Reading Papers of particular interest, aspirin and plavix combination, published recently, have been highlighted as: Clopidogrel and aspirin vs aspirin alone for the treatmend of high-risk patients with acute non-disabling cerebrovascular events CHANCE: Stroke in developing countries: Aspirin in the aspirin and plavix combination and secondary prevention of vascular disease: Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke.
Aspirin and extended-release dipyridamole vs clopidogrel for recurrent stroke. N Engl J Med. Population-based study of risk and predictors of stroke in the first few hours after a TIA. Aspirin and clopidogrel compared with clopidogrel alone after recent ischemic stroke or transient ischemic attack in high-risk patients MATCH: