ANTIPLATELET TREATMENT IN PATIENTS WHO HAVE AN ISCHEMIC STROKE WHILE TAKING ASPIRIN

Konstantinos Tziomalos, Stella D. Bouziana, Marianna Spanou, Stavroula Kostaki, Maria Papadopoulou,

Vasilios Giampatzis, Maria Tsopozidi, Stella-Maria Angelopoulou, Christos Savopoulos, Apostolos I. Hatzitolios

 

First Propedeutic Department of Internal Medicine,

Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece

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Introduction - Objectives

The optimal antiplatelet treatment in patients who have an ischemic stroke while taking aspirin is unknown

In patients with cardiovascular disease, increasing the dose of aspirin is associated with higher risk of gastrointestinal bleeding without further reduction in the risk of cardiovascular events

In the CAPRIE trial (n = 19,185), clopidogrel was not more effective than aspirin in reducing cardiovascular events in patients with a history of ischemic stroke

In the CHARISMA trial (n = 12,153), clopidogrel plus aspirin reduced cardiovascular events more than aspirin monotherapy in patients with established cardiovascular disease but also increased the risk of major bleeding

The aim of the present study was to compare two strategies in patients who have an ischemic stroke while taking aspirin, i.e. continuing aspirin at the same dose or switching to clopidogrel monotherapy

BMJ 2002;324:71-86

Lancet 1996;348:1329-39

N Engl J Med 2006;354:1706-17

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Patients and methods

We prospectively studied 436 patients (39.2% males, age 78.6±6.7 years) who were consecutively discharged after acute ischemic stroke

One year after discharge, patients and/or their relatives were contacted by phone and the incidence of nonfatal ischemic stroke, nonfatal myocardial infarction, cardiovascular death and all-cause mortality were recorded

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Results (I) – Characteristics of patients at discharge

At admission, 41 patients (9.4% of the total study population) were being treated with aspirin 100 mg/day and had sinus rhythm

At discharge, these patients were prescribed aspirin 100 mg/day (n=12) or clopidogrel (n=29)

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Patients treated with aspirin(n = 12)

Patients treated with clopidogrel(n = 29)

p

Age (years) 78.6±4.2 77.4±8.7 0.647

Males (%) 50.0 50.0 1.000

Hypertension (%) 100.0 69.2 0.038

Diabetes mellitus (%) 9.1 50.0 0.019

Coronary heart disease (%) 50.0 50.0 1.000

Smoking (current/past, %) 8.3/8.3 10.3/24.1 0.566

Obesity (%) 0.0 38.9 0.031

LDL cholesterol (mg/dl) 107±28 94±27 0.250

HDL cholesterol (mg/dl) 41±15 40±13 0.787

Triglycerides (mg/dl) 112±59 125±45 0.520

Modified Rankin scale 2.1±1.8 2.1±1.9 0.987

Results (II) – Outcome of patients at 1 year after discharge

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Patients treated with aspirin(n = 12)

Patients treated with clopidogrel(n = 29)

p

Nonfatal ischemic stroke (%) 27.3 25.0 0.890

Nonfatal myocardial infarction (%) 18.2 5.0 0.235

Cardiovascular mortality (%) 10.0 10.5 0.965

All-cause mortality (%) 27.3 20.0 0.643

Conclusions

In patients who suffer ischemic stroke despite aspirin treatment, switching to clopidogrel appears to be more appropriate than continuing aspirin at the same dose

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