Monday, August 2, 2010

Stroke and antiplatelets - Aspirin or dipyridamole or plavix?

Todays morning report was about a 63 yo female presenting with slurred speech and some left sided weakness while she was on Aspirin. MRI showed a brainstem infarct. What would be her antiplatelet mnagement?

lets look at some evidence for secondary prevention.There are 2 studies we can quickly look at

1.European Stroke Prevention study (ESPS2) - nearly 7000 patients with TIA/stroke were randomised to ASA or Dipyridamole or both. Primary end point was stroke/death. follw up for 2 years showed a similar risk reduction (13%) in both ASA and dipyridamole groups. The aggrenox group had a 37% risk reduction. Another study ,ESPIRIT in 2006 also showed same benifit.

2. PROFESS trial - this was published in NEJM recently. 20 332 patients from 695 sites in 35 countries. All had had a noncardioembolic ischemic stroke within the previous 120 days.They were randomized to receive Aggrenox bid or clopidogrel (75 mg) once daily.primary outcome was recurrent stroke. There was no difference between the two agents, except for a nonsignificant increase in major hemorrhagic events(4.1% Vs 3.6%). Conclusion- Plavix is not inferior to aggrenox in secondary prevention of stroke.

These two studies (and a few other studies like MATCH which compared ASA with ASA & plavix) made changes to the AHA guidelines for stroke.

The current recommendation is that aggrenox is superior to ASA alone, but all 3 agents(ASA, aggrenox, Plavix) can be used as first line antiplatelets in patients with non carioembolic stroke.


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