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• W2040094554 abstract "Carotid atheromatous disease is an important cause of stroke and represents a key target in stroke prevention. Randomized trials have shown the efficacy of carotid endarterectomy in secondary stroke prevention. Carotid stenting presents a less invasive alternative to surgical intervention. Advances in medical management, if compliance can be ensured, are leading to improvement in outcomes when implemented as sole therapy in the treatment of atherosclerotic carotid stenosis. This includes lifestyle modification, blood pressure control, and antiplatelet and statin therapy. Over the last 20 years, the annual rate of ipsilateral stroke associated with asymptomatic carotid stenosis has decreased from 2% to 4% to less than 1%. This is largely due to improvements in medical therapy. However, despite numerous trials and years of clinical research, the optimal management of symptomatic and asymptomatic carotid disease remains controversial. This article presents and summarizes the evidence supporting best medical treatment for carotid artery stenosis. Carotid atheromatous disease is an important cause of stroke and represents a key target in stroke prevention. Randomized trials have shown the efficacy of carotid endarterectomy in secondary stroke prevention. Carotid stenting presents a less invasive alternative to surgical intervention. Advances in medical management, if compliance can be ensured, are leading to improvement in outcomes when implemented as sole therapy in the treatment of atherosclerotic carotid stenosis. This includes lifestyle modification, blood pressure control, and antiplatelet and statin therapy. Over the last 20 years, the annual rate of ipsilateral stroke associated with asymptomatic carotid stenosis has decreased from 2% to 4% to less than 1%. This is largely due to improvements in medical therapy. However, despite numerous trials and years of clinical research, the optimal management of symptomatic and asymptomatic carotid disease remains controversial. This article presents and summarizes the evidence supporting best medical treatment for carotid artery stenosis. Internal carotid artery stenosis is an important cause of ischemic stroke, and the treatment of carotid artery stenosis has been a topic of intense debate over the last 30 years. The benefits of surgical intervention in severe symptomatic stenosis have been well documented by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) trials.1North American Symptomatic Carotid Endarterectomy Trial CollaboratorsBeneficial effect of carotid endarterectomy in symptomatic patients with high grade carotid stenosis.N Engl J Med. 1991; 325: 445-453Crossref PubMed Scopus (7865) Google Scholar, 2MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or mild (0-29%) carotid stenosis. European Carotid Surgery Trialist's Collaborative Group.Lancet. 1991; 337: 1235-1243Abstract PubMed Scopus (3126) Google Scholar Major advances have been made regarding medical therapy alongside lifestyle changes over the last 20 years since the first trials were published, and there is emerging evidence in favor of aggressive medical management that may reduce the compelling indications for surgery/stenting in asymptomatic populations.3Davies K.J. Thapar A. Kasivisvanathan V. Shalhoub J. Davies A.H. Review of trans-atlantic cardiovascular best medical therapy guidelines - recommendations for asymptomatic carotid atherosclerosis.Curr Vasc Pharmacol. 2013; 11: 514-523Crossref PubMed Scopus (16) Google Scholar This report aims to evaluate the evidence of best medical treatment for carotid artery stenosis. A literature search of MEDLINE, Cochrane, and EMBASE databases was performed to identify all studies that evaluated the use of statins, antiplatelets, anticoagulants, antihypertensives, and antiglycemics in vascular disease. The studies considered for review were cohort studies, randomized controlled trials (RCTs), meta-analyses, and systematic reviews. Studies investigating the effect of statin therapy in patients with carotid artery stenosis and stroke rates are listed in Table I.4Nicholls S.J. Borgman M. Nissen S.E. Raichlen J.S. Ballantyne C. Barter P. et al.Impact of statins on progression of atherosclerosis: rationale and design of SATURN (Study of Coronary Atheroma by InTravascular Ultrasound: effect of Rosuvastatin versus AtorvastatiN).Curr Med Res Opin. 2011; 27: 1119-1129Crossref PubMed Scopus (39) Google Scholar, 5Amarenco P. Bogousslavsky J. Callahan 3rd, A. Goldstein L.B. Hennerici M. Rudolph A.E. et al.Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack.N Engl Med. 2006; 355: 549-559Crossref PubMed Scopus (2319) Google Scholar, 6Sillesen H. Amarenco P. Hennerici M.G. Callahan A. Goldstein L.B. Zivin J. et al.Atorvastatin reduces the risk of cardiovascular events in patients with carotid atherosclerosis: a secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial.Stroke. 2008; 39: 3297-3302Crossref PubMed Scopus (222) Google Scholar, 7Hegland O. Dickstein K. Larsen J.P. Effect of simvastatin in preventing progression of carotid artery stenosis.Am J Cardiol. 2001; 87: 643-645Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 8Paraskevas K.I. Hamilton G. Mikhailidis D.P. Statins: an essential component in the management of carotid artery disease.J Vasc Surg. 2007; 46: 373-386Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 9LaRosa J.C. Grundy S.M. Waters D.D. Shear C. Barter P. Fruchart J.C. et al.Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease.N Engl J Med. 2005; 352: 1425-1435Crossref PubMed Scopus (3014) Google Scholar, 10Pedersen T.R. Faergeman O. Kastelein J.J. Olsson A.G. Tikkanen M.J. Holme I. et al.Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) Study group. High dose atorvastatin vs usual dose simvastatin for secondary prevention after myocardial infarction: the IDEAL study: a randomized controlled trial.JAMA. 2005; 294: 2437-2445Crossref PubMed Scopus (1375) Google Scholar, 11Heart Protection Study Collaborative GroupMRC/BHF heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized controlled trial.Lancet. 2002; 360: 7-22Abstract Full Text Full Text PDF PubMed Scopus (7642) Google Scholar The majority (five RCTs) used atorvastatin as one part of the study.4Nicholls S.J. Borgman M. Nissen S.E. Raichlen J.S. Ballantyne C. Barter P. et al.Impact of statins on progression of atherosclerosis: rationale and design of SATURN (Study of Coronary Atheroma by InTravascular Ultrasound: effect of Rosuvastatin versus AtorvastatiN).Curr Med Res Opin. 2011; 27: 1119-1129Crossref PubMed Scopus (39) Google Scholar, 5Amarenco P. Bogousslavsky J. Callahan 3rd, A. Goldstein L.B. Hennerici M. Rudolph A.E. et al.Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack.N Engl Med. 2006; 355: 549-559Crossref PubMed Scopus (2319) Google Scholar, 6Sillesen H. Amarenco P. Hennerici M.G. Callahan A. Goldstein L.B. Zivin J. et al.Atorvastatin reduces the risk of cardiovascular events in patients with carotid atherosclerosis: a secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial.Stroke. 2008; 39: 3297-3302Crossref PubMed Scopus (222) Google Scholar, 9LaRosa J.C. Grundy S.M. Waters D.D. Shear C. Barter P. Fruchart J.C. et al.Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease.N Engl J Med. 2005; 352: 1425-1435Crossref PubMed Scopus (3014) Google Scholar, 10Pedersen T.R. Faergeman O. Kastelein J.J. Olsson A.G. Tikkanen M.J. Holme I. et al.Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) Study group. High dose atorvastatin vs usual dose simvastatin for secondary prevention after myocardial infarction: the IDEAL study: a randomized controlled trial.JAMA. 2005; 294: 2437-2445Crossref PubMed Scopus (1375) Google Scholar In only one of the RCTs, atorvastatin was shown to have a nonsignificant reduction in relative risk (RR) of stroke.6Sillesen H. Amarenco P. Hennerici M.G. Callahan A. Goldstein L.B. Zivin J. et al.Atorvastatin reduces the risk of cardiovascular events in patients with carotid atherosclerosis: a secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial.Stroke. 2008; 39: 3297-3302Crossref PubMed Scopus (222) Google Scholar A systematic review further showed that atorvastatin consistently reduced low-density lipoprotein (LDL) levels to <76 mg/dL. Each 10% reduction in LDL reduced the risk of stroke by 15% (95% confidence interval [CI], 6.7-23.6).8Paraskevas K.I. Hamilton G. Mikhailidis D.P. Statins: an essential component in the management of carotid artery disease.J Vasc Surg. 2007; 46: 373-386Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Three studies looked at simvastatin, showing that there was a significant regression in carotid plaques, and there was also a significant reduction in incidence of stroke.7Hegland O. Dickstein K. Larsen J.P. Effect of simvastatin in preventing progression of carotid artery stenosis.Am J Cardiol. 2001; 87: 643-645Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 10Pedersen T.R. Faergeman O. Kastelein J.J. Olsson A.G. Tikkanen M.J. Holme I. et al.Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) Study group. High dose atorvastatin vs usual dose simvastatin for secondary prevention after myocardial infarction: the IDEAL study: a randomized controlled trial.JAMA. 2005; 294: 2437-2445Crossref PubMed Scopus (1375) Google Scholar, 11Heart Protection Study Collaborative GroupMRC/BHF heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized controlled trial.Lancet. 2002; 360: 7-22Abstract Full Text Full Text PDF PubMed Scopus (7642) Google Scholar The Study of Coronary Atheroma by Intravascular Ultrasound: Effect of Rosuvastatin vs Atorvastatin (SATURN) randomly assigned 1385 patients to full-dose statin treatment. The study showed that both statins significantly reduced LDL cholesterol levels.4Nicholls S.J. Borgman M. Nissen S.E. Raichlen J.S. Ballantyne C. Barter P. et al.Impact of statins on progression of atherosclerosis: rationale and design of SATURN (Study of Coronary Atheroma by InTravascular Ultrasound: effect of Rosuvastatin versus AtorvastatiN).Curr Med Res Opin. 2011; 27: 1119-1129Crossref PubMed Scopus (39) Google Scholar There was a regression in atherosclerosis (68.5% vs 63.2% with atorvastatin), but there was no statistical difference between them (P = .17). Over the course of 104 weeks, there were two nonfatal strokes with atorvastain and three with rosuvastatin.4Nicholls S.J. Borgman M. Nissen S.E. Raichlen J.S. Ballantyne C. Barter P. et al.Impact of statins on progression of atherosclerosis: rationale and design of SATURN (Study of Coronary Atheroma by InTravascular Ultrasound: effect of Rosuvastatin versus AtorvastatiN).Curr Med Res Opin. 2011; 27: 1119-1129Crossref PubMed Scopus (39) Google ScholarTable ITrials investigating the effect of statins on the incidence of strokeAuthorStudy designInclusion criteriaAimTreatmentPatientsResults/main conclusionsNicholls SJ et al; SATURN Study, 20114Nicholls S.J. Borgman M. Nissen S.E. Raichlen J.S. Ballantyne C. Barter P. et al.Impact of statins on progression of atherosclerosis: rationale and design of SATURN (Study of Coronary Atheroma by InTravascular Ultrasound: effect of Rosuvastatin versus AtorvastatiN).Curr Med Res Opin. 2011; 27: 1119-1129Crossref PubMed Scopus (39) Google ScholarRCT, double blind, multicenterAt least 1 vessel with 20% stenosis in coronary arteries on angiography.LDL >100 mg/dL if no prior statin treatment.LDL >80 mg/dL if prior treatment.To assess the effects of two intensive statin regimens on coronary atherosclerosis progression using intravascular USS using PAVAtorvastatin 80 mg vs rosuvastatin 40 mg1385 (691/694)Patients with rosuvastatin had lower levels of LDL than those treated with atorvastatin (62.6 vs 70.2 mg/dL; P < .001).Two-thirds of patients demonstrated some form of regression of atherosclerosis (68.5% vs 63.3% with atorvastatin).Though overall PAV decreased by 1.22% (95% CI, −1.52-−0.90; P = .17) with rosuvastatin and 0.99% (95% CI, −1.19-−0.63) with atorvastatin.Nonfatal stroke 3 (0.4%) for rosuvastatin and 2 (0.3%) for atorvastatinDifficult to apply to asymptomatic patients.Amarenco et al; SPARCL Study, 20065Amarenco P. Bogousslavsky J. Callahan 3rd, A. Goldstein L.B. Hennerici M. Rudolph A.E. et al.Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Investigators. High-dose atorvastatin after stroke or transient ischemic attack.N Engl Med. 2006; 355: 549-559Crossref PubMed Scopus (2319) Google ScholarRCT, double blind, multicenter1)No CAD2)TIA or stroke within last 6 monthsTime from randomization to first nonfatal or fatal strokeAtorvastatin 80 mg daily vs placebo4731 (2365/2366)Atorvastatin: 16% RR reduction (95% CI, 0.71-0.99; P = .03) and 35% reduction in major coronary vascular events.Sillesen H et al;Secondary analysis of SPARCL Study, 20086Sillesen H. Amarenco P. Hennerici M.G. Callahan A. Goldstein L.B. Zivin J. et al.Atorvastatin reduces the risk of cardiovascular events in patients with carotid atherosclerosis: a secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial.Stroke. 2008; 39: 3297-3302Crossref PubMed Scopus (222) Google ScholarAs per SPARCL studyAnalysis of patients included those with carotid artery stenosisPatients with carotid artery stenosisGreatest reduction of stroke in patients with carotid artery stenosisAtorvastatin 80 mg vs placebo100751% stenosis (±29%)In atorvastatin treatment group1)33% reduction in the risk of any stroke (HR, 0.67; 95% CI, 0.47-0.94; P = .02)2)43% reduction in risk of major coronary event (HR, 0.57; 95% CI, 0.32-1.00; P = .05)Absolute risk reduction of stroke was 1% per year (numbers needed to treat, 20 over 5 years).Hegland O et al, 20017Hegland O. Dickstein K. Larsen J.P. Effect of simvastatin in preventing progression of carotid artery stenosis.Am J Cardiol. 2001; 87: 643-645Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarSingle-center prospective cohort, longitudinal study1)Carotid artery stenosis >40%2)>2 measurements of stenosis3)No previous surgical interventionTo assess the effect of simvastatin on carotid plaquesSimvastatin treated vs no statin at baseline observation230 (147/171); 318 arteries13.5% regression in carotid stenosis in the simvastatin group and a mean progression of carotid stenosis of 6.4% in the untreated group.Paraskevas KI et al, 20078Paraskevas K.I. Hamilton G. Mikhailidis D.P. Statins: an essential component in the management of carotid artery disease.J Vasc Surg. 2007; 46: 373-386Abstract Full Text Full Text PDF PubMed Scopus (70) Google ScholarSystematic review of statin effect on carotid IMT and carotid artery disease progression ratesAll studies assessing impact of statin therapy on carotid IMT progression and stroke ratesTo define the role of statin treatment in patients with carotid artery diseaseNACarotid IMT1)2 meta-analysis (n > 93,443)2)24 studies (n = 6727)Statin and stroke rates27 studies (n = 127,833)Carotid IMT and statinTotal weighted mean difference of carotid IMT progression between statins vs placebo was −22.35% (95% CI, 18.14-−26.56%; P < .00001)Atorvastatin 80 mg/d for 12 months resulted in a 48.5% decrease in LDL cholesterol (148 ± 32 to 76 ± 23 mg/dL). Pravastatin reduced LDL levels by 27.2% (155 ± 34 to 110 ± 30 mg/dL).Statins and stroke ratesEach 10% reduction in LDL cholesterol was estimated to reduce the risk of stroke by 15.6% (95% CI, 6.7-23.6).Clinical vascular eventsStatin therapy was associated with a 12% reduction in all-cause mortality per mmol/L reduction in LDL cholesterol (95% CI, 9%-16%; P < .0001).LaRosa J et al; TNT Study, 20059LaRosa J.C. Grundy S.M. Waters D.D. Shear C. Barter P. Fruchart J.C. et al.Treating to New Targets (TNT) Investigators. Intensive lipid lowering with atorvastatin in patients with stable coronary disease.N Engl J Med. 2005; 352: 1425-1435Crossref PubMed Scopus (3014) Google ScholarRCT, double blind, multicenterCHD and LDL level <130 mg/dL1)Reducing LDL cholesterol <100 mg/dL in stable CHD2)The occurrence of death, MI, fatal or nonfatal strokeAtorvastatin low dose (10 mg) vs high dose (80 mg)10,001 (5006/4995)Fatal or nonfatal stroke; 10 mg, 155 (3.1%) vs 80 mg, 117 (2.3%) (HR, 0.75; 95% CI, 0.59-0.96; P = .02).Cerebrovascular events (stroke or TIA) 10 mg, 250 (5.0%) vs 80 mg, 196 (3.9%) (HR, 0.77; 95% CI, 0.64-0.93; P .007).Mean LDL 77 mg/dL for high-dose and 101 mg/dL for low-dose treatment.8.1 vs 5.8%; P < .001 had an adverse event related to treatment for high dose and low dose respectively.Pedersen et al; IDEAL Study, 200510Pedersen T.R. Faergeman O. Kastelein J.J. Olsson A.G. Tikkanen M.J. Holme I. et al.Incremental Decrease in End Points Through Aggressive Lipid Lowering (IDEAL) Study group. High dose atorvastatin vs usual dose simvastatin for secondary prevention after myocardial infarction: the IDEAL study: a randomized controlled trial.JAMA. 2005; 294: 2437-2445Crossref PubMed Scopus (1375) Google ScholarRCT, open label, multicenter1)<80 years2)History of acute MIOccurrence of a major coronary event (eg, death, nonfatal MI)Atorvastatin 80 mg vs simvastatin 20 mg8888 (4449/4439)Secondary outcome: fatal or nonfatal stroke. 151 (3.4%) atorvastatin vs 174 (3.9%) simvastatin (HR, 0.87; 95% CI, 0.70-1.08; P = .20).Cardiovascular mortality 223 (5.0%) atorvastatin vs 218 (4.9%) simvastatin (HR, 1.03; 95% CI, 0.85-1.24; P = .78).Heart Protection Study, 200211Heart Protection Study Collaborative GroupMRC/BHF heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomized controlled trial.Lancet. 2002; 360: 7-22Abstract Full Text Full Text PDF PubMed Scopus (7642) Google ScholarRCT, double blind, multicenter1)LDL > 135 mg/dL,2)History ofa)CHD,b)occlusive disease of noncoronary arteries (ie TIA, stroke,c)Previous CEATo assess the long-term effects of lowering LDL cholesterol on vascular and nonvascular mortalitySimvastatin 40 mg vs placebo20, 536 (10,269/10,267)17% reduction in the death rate from vascular causes: 781 (7.6%) for simvastatin vs 937 (9.1%) for placebo; P < .0001.25% reduction in incidence of stroke444 (4.3%) simvastatin vs 585 (5.7%) placebo; P < .0001.30% reduction in ischemic stroke290 simvastatin (2.8%) vs 409 placebo (4.0%); P < .0001.CAD, Coronary artery disease; CEA, carotid endarterectomy; CHD, coronary heart disease, CI, confidence interval; IMT, intima-media thickness; LDL, low-density lipoprotein; MI, myocardial infarction; NA, not available; PAV, percent atheroma volume; RCT, randomized controlled trial; RR, relative risk; TIA, transient ischemic attack; USS, ultrasound scan. Open table in a new tab CAD, Coronary artery disease; CEA, carotid endarterectomy; CHD, coronary heart disease, CI, confidence interval; IMT, intima-media thickness; LDL, low-density lipoprotein; MI, myocardial infarction; NA, not available; PAV, percent atheroma volume; RCT, randomized controlled trial; RR, relative risk; TIA, transient ischemic attack; USS, ultrasound scan. Antiplatelet therapy has been shown to reduce the incidence of stroke by 25% (P < .0001).12Antithrombotic Trialists CollaborationCollaborative meta-analysis of randomised trials of anti-platelet therapy for prevention of death, myocardial infarction and stroke in high risk patients.BMJ. 2002; 324: 71-86Crossref PubMed Google Scholar One meta-analysis analyzed 21 trials involving 18,270 patients.12Antithrombotic Trialists CollaborationCollaborative meta-analysis of randomised trials of anti-platelet therapy for prevention of death, myocardial infarction and stroke in high risk patients.BMJ. 2002; 324: 71-86Crossref PubMed Google Scholar It showed that most of the evidence supported the use of aspirin in the range of 75 mg to 150 mg and was unable to support the use of dual antiplatelets due to lack of evidence.12Antithrombotic Trialists CollaborationCollaborative meta-analysis of randomised trials of anti-platelet therapy for prevention of death, myocardial infarction and stroke in high risk patients.BMJ. 2002; 324: 71-86Crossref PubMed Google Scholar The CHARISMA trial compared aspirin and clopidogrel against aspirin alone in both symptomatic and asymptomatic patients. Initial analysis showed that the rate of primary event of stroke was similar in both groups (6.8% vs 7.3%; P = .22).13Bhatt D.L. Fox K.A. Hacke W. Berger P.B. Black H.R. Boden W.E. for the CHARISMA investigators et al.Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events.N Engl J Med. 2006; 354: 1706-1717Crossref PubMed Scopus (2443) Google Scholar A Cochrane review assessed the efficacy and safety of dipyridamole in the secondary prevention of vascular events (death from all vascular causes, nonfatal stroke/myocardial infarction [MI]) in patients with vascular disease. The review looked at 26 RCTs, which compared 39 treatments in a total of 19,842 patients with the dose varying between 150 mg and 800 mg daily.14De Schryver E.L.L.M. Algra A. Van Gijn J. Cochrane Review: dipyridamole for preventing major vascular events in patients with vascular disease.Stroke. 2003; 34: 2072-2080Crossref PubMed Scopus (45) Google Scholar Eighteen trials compared dipyridamole with placebo and showed that it had no effect on vascular death but did reduce the risk of having a vascular event RR, 1.02; 95% CI, 0.90-1.17 vs RR, 0.90; 95% CI, 0.83-0.98).14De Schryver E.L.L.M. Algra A. Van Gijn J. Cochrane Review: dipyridamole for preventing major vascular events in patients with vascular disease.Stroke. 2003; 34: 2072-2080Crossref PubMed Scopus (45) Google Scholar Combining dipyridamole with aspirin again had no effect on vascular deaths but did reduce the risk of having a vascular event similar to that seen with dipyridamole alone (RR, 1.03; 95% CI, 0.87-1.22 vs RR, 0.90; 95% CI, 0.80-1.00).14De Schryver E.L.L.M. Algra A. Van Gijn J. Cochrane Review: dipyridamole for preventing major vascular events in patients with vascular disease.Stroke. 2003; 34: 2072-2080Crossref PubMed Scopus (45) Google Scholar The review did not find any evidence to support the use of dipyridamole as the first-line antiplatelet in patients at high risk of a vascular event.14De Schryver E.L.L.M. Algra A. Van Gijn J. Cochrane Review: dipyridamole for preventing major vascular events in patients with vascular disease.Stroke. 2003; 34: 2072-2080Crossref PubMed Scopus (45) Google Scholar Other studies analyzed are presented in Table II.15Diener H.C. Bogousslavsky J. Brass L.M. Cimminiello C. Csiba L. Kaste M. et al.Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial.Lancet. 2004; 364: 331-337Abstract Full Text Full Text PDF PubMed Scopus (1945) Google Scholar, 16CAPRIE Steering Committee A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events.Lancet. 1996; 348: 1329-1339Abstract Full Text Full Text PDF PubMed Scopus (6109) Google Scholar, 17Diener H.C. Cunha L. Forbes C. Sivenius J. Smets P. Lowentha A. European Stroke Prevention Study 2. Dipyridamole and acetyl-salicyclic acid in the secondary prevention of stroke.J Neurol Sci. 1996; 143: 1-13Abstract Full Text Full Text PDF PubMed Scopus (1735) Google Scholar, 18ESPRIT Study Group Halkes P.H. van Gijn J. Kappelle L.J. Koudstaal P.J. Algra A. Aspirin plus dipyridamole versus aspirin alone after cerebral ischaemia of arterial origin (ESPRIT): randomised controlled trial.Lancet. 2006; 367: 1665-1673Abstract Full Text Full Text PDF PubMed Scopus (915) Google Scholar, 19Mehta S.R. Yusuf S. Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Study Investigators. The Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial programme; rationale, design and baseline characteristics including a meta-analysis of the effects of thienopyridines in vascular disease.Eur Heart J. 2000; 21: 2033-2041Crossref PubMed Scopus (281) Google Scholar, 20Sacco R.L. Diener H.C. Yusuf S. Cotton D. Ounpuu S. Lawton W.A. et al.Aspirin and extended-release dipyridamole versus clopidrogrel for rcurrent stroke.N Engl J Med. 2008; 359: 1238-1251Crossref PubMed Scopus (820) Google Scholar, 21Farrell B. Godwin J. Richards S. Warlow C. The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results.J Neurol Neurosurg Psychiatry. 1991; 54: 1044-1105Crossref PubMed Scopus (961) Google ScholarTable IITrials investigating antiplatelet treatment in vascular diseaseAuthorStudy designInclusion criteriaAimTreatmentPatientsResults/main conclusionDiener HC et al; MATCH Study, 200415Diener H.C. Bogousslavsky J. Brass L.M. Cimminiello C. Csiba L. Kaste M. et al.Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial.Lancet. 2004; 364: 331-337Abstract Full Text Full Text PDF PubMed Scopus (1945) Google ScholarRCT, double-blind, multicenter (507 centers in 28 countries)TIA or ischemic stroke in last 3 months and had 1 or more risk factors within the last 3 years:a)Previous stroke/MIb)Diabetesc)Symptomatic peripheral vascular diseasePrimary end point was:Ischemic strokeVascular deathRehospitalization for an acute ischemic eventSafetya)Incidence of life-threatening bleedingb)Intracranial bleedingc)Need of >4 units of RBCsAspirin 75 mg vs placeboAll patients also taking clopidogrel7599 (3802 placebo + clopidogrel 3797 aspirin + clopidogrel)18-month follow-upPrimary outcome was 16% in aspirin group vs 17% in placebo group (P = .244).Ischemic stroke (fatal or not) 8% in both groups.3% of patients in the aspirin group had life-threatening bleeding compared with 1% in the placebo group (RR, 1.26; 95% CI, 0.64-1.88; P < .0001).GI bleeding was that most common cause (1.4% vs 0.6%). No hemorrhagic transformation of ischemic stroke.Benefit-to-risk ratio showed no added benefit of aspirin and clopidogrel.Antithrombotic Trialists Collaboration, BMJ 200212Antithrombotic Trialists CollaborationCollaborative meta-analysis of randomised trials of anti-platelet therapy for prevention of death, myocardial infarction and stroke in high risk patients.BMJ. 2002; 324: 71-86Crossref PubMed Google ScholarMeta-analysis, 287 studies (up to Sept 1997)NATo update previous meta-analyses to include studies up to September 1997.Main outcome measure:Serious vascular eventsNonfatal MINonfatal strokeVascular deathAntiplatelet vs controlAntiplatelet vs antiplatelet135,000 (antiplatelet vs control)77,000 (antiplatelet vs antiplatelet)Antiplatelet therapy produced a 25% reduction in nonfatal strokes (P < .0001)18, 270 patients/21 trials29 months of antiplatelet –25 (5%) fewer/1000; P < .0001Asymptomatic carotid disease 36/339 (10.6%) antiplatelet v 43/337 (12.8%) adjusted control = 19% (22% reduction, NS)No evidence to support 500-1000 mg of aspirin (more gastro toxic)Evidence supports aspirin in the range of 75 mg to 150 mg.150-300 mg should be given as a loading dose in an acute stroke.Clopidogrel may be slightly more effective, consider as alternative if aspirin contra-indicated.Dual therapy – more research is needed.CAPRIE, 199616CAPRIE Steering Committee A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events.Lancet. 1996; 348: 1329-1339Abstract Full Text Full Text PDF PubMed Scopus (6109) Google ScholarRCT, blinded, international, multicenter (384)a)Ischemic stroke >1 week and <6 months prior to randomizationb)MI onset <35 days prior to randomizationc)Intermittent claudicationPatients with CEA excludedTo assess the impact of clopidogrel on the reduction of ischemic stroke, MI, or vascular death in patients with recent eventsClopidogrel 75 mg vs aspirin 325 mg19,185 (9553 clopidogrel/9546 aspirin)Patients on clopidogrel had annual risk of ischemic stroke/MI/vascular death of 5.32% compared with 5.83% with aspirin.There was an RR reduction of 8.7% (95% CI, 0.3-16.5; P = .043).Expect 24 clincial events to be prevented per 1000 patients with clopidogrel compared with 19 with aspirin.European Stroke Prevention Study 217Diener H.C. Cunha L. Forbes C. Sivenius J. Smets P. Lowentha A. European Stroke Prevention Study 2. Dipyridamole and acetyl-salicyclic acid in the secondary prevention of stroke.J Neurol Sci. 1996; 143: 1-13Abstract Full Text Full Text PDF PubMed Scopus (1735) Google Scholar; Diener HC et al, 1996RCT, double-blindTIA or stroke within the last 3 monthsPrimary outcomes1)Stroke (first occurrence fatal and nonfatal)2)Death from all causesSecondary outcomes1)TIA2)MIFour treatment groupsa)Aspirin 25 mg BIDb)200 mg BID dipyridamole modified releasec)Combination of treatment (a and b)d)Matched placebo6602 in totala)1649b)1654c)1650d)164912.9% stroke rate in aspirin alone, 13.2% in dipyridamole modified release, 9.9% in combination, 15.8% in placebo.No difference between the groups for end point of death (P = .616).RR reduction for stroke with1)Aspirin = 18.1" @default.
• W2040094554 created "2016-06-24" @default.
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