Comparison of the European and Japanese Guidelines for the Management of Ischemic Stroke

Abstract

Background: Different aspects of acute stroke management and strategies for stroke prevention derive from two viewpoints: specific traditional and historical backgrounds and evidence-based medicine from modern randomized controlled trials (RCTs), meta-analysis and authorized clinical practice guidelines (GLs). Regarding stroke, GLs have been published by national and international organizations in different languages, most frequently in English. Cerebrovascular Diseases published the European GLs for the management of ischemic stroke and transient ischemic attacks in 2003, with an update in 2008. At about the same time (in 2004), the first Japanese GLs for the management of stroke appeared in Japanese. The first English version of the updated Japanese GLs was published only in 2011 and included differently approved drugs and drug dosages as compared with other American or European countries. Methods: Since 2011, the authors have met repeatedly and have compared the latest versions of published European and Japanese GLs for ischemic and hemorrhagic strokes. Many aspects have only been addressed in one but left out in the other GLs, which consequently founded the basis for the comparison. Classification of evidence levels and recommendation grades defined by the individual committees differed between both original GLs. Results: Aspects of major importance were surprisingly similar and hence did not need extensive interpretation. Other aspects of ischemic stroke management differed significantly, e.g. the dosage of recombinant tissue plasminogen activator approved in Japan is lower (0.6 mg/kg) than in Europe (0.9 mg/kg), which derived from different practices in cardiovascular treatment prior to the design of acute ischemic stroke RCTs. Furthermore, comedication with neuroprotective agents (edaravone), intravenous anticoagulants (argatroban) or antiplatelet agents within 1-2 days after stroke onset is recommended in Japan but not in Europe. For cardioembolic stroke prevention, a major difference consists in a higher international normalized ratio target (2.0-3.0) in younger subjects versus in those >70 years (1.6-2.6), without age restrictions in Europe. Conclusion: This brief survey - when compared with the lengthy original recommendations - provides a stimulating basis for an extended interest among Japanese and European stroke clinicians to learn from their individual experiences and to strengthen efforts for joint cooperation in treating and preventing stroke all around the globe.

Recanalization Therapies in Acute Ischemic Stroke Patients

“…All participating centers applied IVT/IAT according to wellestablished criteria and guidelines, 7,26 with the exception that, in selected patients, NOAC treatment was not considered an absolute exclusion criterion.…”

Outcomes of Argatroban Treatment in Patients With Atherothrombotic Stroke

“…Argatroban patients were also more likely to receive histamine-2 receptor blockers, which are recommended for use in older patients and patients with severe stroke in the Japanese guidelines for treatment of acute ischemic stroke. 2 This tendency would also indicate that argatroban was used for patients with severe stroke in Japan.…”

“…The present study analyzed 2289 pairs of patients and suggested that argatroban was not associated with more favorable outcomes at least according to its recommended use in Japan. 2 In the present study, we evaluated the effect of argatroban monotherapy on stroke outcomes. On the contrary, the Argatroban tPA Stroke Study (ARTSS-1) evaluated the safety of argatroban use in combination with r-tPA in patients with ischemic stroke.…”

“…1,2 In the Japanese guidelines, it is stated that there is no scientific evidence for the use of heparin, heparinoid drugs, or low molecular weight heparin in patients with acute ischemic stroke. In contrast, argatroban, a selective thrombin inhibitor, is recommended in Japan for the use in patients with acute atherothrombotic stroke except those with lacunar infarction.…”

“…In contrast, argatroban, a selective thrombin inhibitor, is recommended in Japan for the use in patients with acute atherothrombotic stroke except those with lacunar infarction. 2 To the best of our knowledge, there are only 3 randomized controlled trials on argatroban use in patients with acute ischemic stroke: 1 from North America 3 and 2 from Japan. 4,5 These studies suggested that argatroban was effective and safe for the use as early anticoagulant therapy in acute ischemic stroke.…”