Anticoagulants Versus Antiplatelet Therapy for Preventing Stroke in Patients With Nonrheumatic Atrial Fibrillation and a History of Stroke or Transient Ischemic Attack

Abstract

P eople with nonrheumatic atrial fibrillation (NRAF) who have had a transient ischemic attack (TIA) or a minor ischemic stroke are at high-risk of recurrent stroke. Both warfarin and aspirin have been shown to reduce the recurrence of vascular events. ObjectivesThe objective of this review was to compare the effect of anticoagulants with antiplatelet agents, for secondary prevention, after a stroke or TIA, in patients with NRAF. Search StrategyThis review has drawn on the search strategy developed for the Stroke Group as a whole. Relevant trials were identified in the Stroke Group Trials Register (last search June 9, 2003). We also contacted researchers in the field to identify further published and unpublished studies. Selection CriteriaRandomized trials comparing oral anticoagulants with antiplatelet agents in patients with NRAF and a previous TIA or minor ischemic stroke. Data Collection and AnalysisBoth reviewers assessed trial quality and extracted data. The main outcomes considered were (1) fatal or nonfatal recurrent stroke; (2) all major vascular events: vascular death (including fatal bleeds), recurrent stroke (both ischemic and hemorrhagic), myocardial infarction, and systemic embolism; (3) any intracranial bleed; (4) major extracranial bleed. ResultsTwo trials were identified. In the European Atrial Implications for PracticeIn patients with NRAF and a recent nondisabling stroke or TIA, oral anticoagulants were more effective than antiplatelet agents for preventing recurrent stroke and major vascular events. However, anticoagulants were associated with a significant increase in the risk of major extracranial bleeds. These data support the routine use of oral anticoagulants in patients with NRAF and a recent nondisabling stroke or TIA. Implications for ResearchThe excess of major extracranial bleeds with warfarin highlights the need to identify safer anticoagulant regimens or new agents of comparable efficacy but greater safety. Similarly, there is a need to identify more effective antiplatelet

Oral anticoagulant treatment: Risk factors involved in 500 intracranial hemorrhages

“…In summary, intracranial bleeding in anticoagulatedtreated patients happened more frequently during the first months of anticoagulation but was not related with worse anticoagulant controls or excessive levels of INR [47,48].…”

Risk vs benefit of anti-thrombotic therapy in ischaemic stroke patients with cerebral microbleeds

“…However, among those with ≥ 5 MB treated with anti-thrombotic agents (mainly a single anti-platelet agent in our cohort), risk of ICH increased substantially to approach 7.6 %, and resulted in 3.8 % mortality. Comparing with the modest benefit of anti-thrombotic agents in secondary stroke prevention (absolute risk reduction 0.69-2.49 % for aspirin and 6 % for Coumadin) [13,14], the extra bleeding risk seems to outweigh the benefit of treatment when there were ≥ 5 MB. On the other hand, there was also a high risk of recurrent CI (15.2 %) in this group.…”

“…From meta-analysis by the APT collaboration group, anti-platelet agent reduces recurrent infarct by an absolute risk of 0.69-2.49 %, whereas, Coumadin reduces recurrent infarct by absolute risk of 6 % per year in patients with atrial fibrillation and prior stroke or transient ischaemic attack [13,14]. Given the small benefit of treatment and the increased risk of ICH with MB, it is still unclear whether anti-thrombotic agents should be avoided in ischaemic stroke patients with multiple MB.…”

Sub-Tenon's anesthesia with aspirin, warfarin, and clopidogrel

“…[1][2][3][4][5][6][7][8][9] There are no studies in the literature to document the hemorrhagic complications of sub-Tenon's anesthesia in patients on clopidogrel. This prospective audit was undertaken to determine whether patients who continue their aspirin, warfarin, or clopidogrel while having cataract surgery under sub-Tenon's anesthesia have an increased incidence of anesthesia-related hemorrhagic complications.…”