Efficacy of Antiplatelet Therapy in Secondary Prevention Following Lacunar Stroke

Abstract

Background and Purpose— Lacunar stroke accounts for ≈25% of ischemic stroke, but optimal antiplatelet regimen to prevent stroke recurrence remains unclear. We aimed to evaluate the efficacy of antiplatelet agents in secondary stroke prevention after a lacunar stroke. Methods— We searched MEDLINE, Embase, and the Cochrane library for randomized controlled trials that reported risk of recurrent stroke or death with antiplatelet therapy in patients with lacunar stroke. We used random effects meta-analysis and evaluated heterogeneity with I 2 . Results— We included 17 trials with 42 234 participants (mean age 64.4 years, 65% male) and follow up ranging from 4 weeks to 3.5 years. Compared with placebo, any single antiplatelet agent was associated with a significant reduction in recurrence of any stroke (risk ratio [RR] 0.77, 0.62–0.97, 2 studies) and ischemic stroke (RR 0.48, 0.30–0.78, 2 studies), but not for the composite outcome of any stroke, myocardial infarction, or death (RR 0.89, 0.75–1.05, 2 studies). When other antiplatelet agents (ticlodipine, cilostazol, and dipyridamole) were compared with aspirin, there was no consistent reduction in stroke recurrence (RR 0.91, 0.75–1.10, 3 studies). Dual antiplatelet therapy did not confer clear benefit over monotherapy (any stroke RR 0.83, 0.68–1.00, 3 studies; ischemic stroke RR 0.80, 0.62–1.02, 3 studies; composite outcome RR 0.90, 0.80–1.02, 3 studies). Conclusions— Our results suggest that any of the single antiplatelet agents compared with placebo in the included trials is adequate for secondary stroke prevention after lacunar stroke. Dual antiplatelet therapy should not be used for long-term stroke prevention in this stroke subtype.

Update on cerebral small vessel disease: a dynamic whole-brain disease

“…Although some trials reported the proportion of lacunar stroke in their study population, the diagnostic criteria varied considerably and the results were not always reported by subgroup. A systematic review of randomised trials found that any single antiplatelet appeared beneficial for secondary prevention of lacunar stroke,95 but the SPS3 trial showed that long-term dual antiplatelet treatment doubled the risk of bleeding without reducing the risk of stroke recurrence in patients with recent lacunar stroke. Also, blood pressure lowering did not show significant reduction in recurrent lacunar stroke in the SPS3 trial, although it was consistent with a modest benefit 96…”

The Benefit and Safety of Aspirin for Primary Prevention of Ischemic Stroke: A Meta-Analysis of Randomized Trials

“…Although it is effective in the secondary prevention of stroke among men and women, its use in primary prevention remains controversial (Cuzick et al, 2015; Kuznar and Uchiyama, 2015; Kwok et al, 2015). The most recent AHA (American Heart Association) guideline for the primary prevention of cardiovascular disease and stroke recommends the use of aspirin in persons whose 10-year risk for coronary heart disease is 6–10% to improve the likelihood of a positive balance of coronary risk reduction over bleeding and hemorrhagic stroke caused by aspirin.…”

Antiplatelet Therapy in Noncardioembolic Stroke: A Review of Current Evidence

“…64 Data from a recent pooled analysis of randomized trials including more than 42,000 patients with lacunar stroke confirmed that combination treatment (aspirin plus dipyridamole or clopidogrel in most cases) did not have benefits over monotherapy with aspirin (RR, 0.95; 95% CI, 0.85-1.07). 65 In summary, the available evidence suggests that aspirin is effective in the secondary prevention of lacunar stroke. The combination of aspirin and dipyridamole is superior to aspirin alone, whereas the combination of aspirin and clopidogrel is not superior to aspirin and is associated with an increased risk of major hemorrhage.…”