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. 2022 Jan 14;1(1):CD000029.
doi: 10.1002/14651858.CD000029.pub4.

Oral antiplatelet therapy for acute ischaemic stroke

Jatinder S Minhas  1 , Tamara Chithiramohan  1 , Xia Wang  2 , Sam C Barnes  1 , Rebecca H Clough  1 , Meeriam Kadicheeni  1 , Lucy C Beishon  1 , Thompson Robinson  1
Affiliations

Oral antiplatelet therapy for acute ischaemic stroke

Jatinder S Minhas et al. Cochrane Database Syst Rev. .

Abstract

Background: In people with acute ischaemic stroke, platelets become activated and can cause blood clots to form and block an artery in the brain, resulting in damage to part of the brain. Such damage gives rise to the symptoms of stroke. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and also reduce the risk of early recurrent ischaemic stroke, thereby reducing the risk of early death and improving long-term outcomes in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage.

Objectives: To assess the efficacy and safety of immediate oral antiplatelet therapy (i.e. started as soon as possible and no later than two weeks after stroke onset) in people with acute presumed ischaemic stroke.

Search methods: We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and two trials registers, and performed forward reference/cited reference searching in August 2020.

Selection criteria: Randomised controlled trials (RCTs) comparing oral antiplatelet therapy (started within 14 days of the stroke) with control in people with definite or presumed ischaemic stroke.

Data collection and analysis: Two review authors independently applied the inclusion criteria and assessed trial quality. For the included trials, they extracted and cross-checked the data. They assessed risk of bias of each study using the Risk of Bias 1 (RoB1) tool and overall certainty of the evidence for each outcome using the GRADE approach.

Main results: We included 11 studies involving 42,226 participants. Three new trials have been added since the last update (743 participants). As per the previous version of this review, two trials testing aspirin 160 mg to 300 mg once daily, started within 48 hours of onset, contributed 96% of the data. The risk of bias was low. The maximum follow-up was six months. With treatment, there was a decrease in death or dependency at the end of follow-up (odds ratio (OR) 0.95, 95% confidence interval (CI) 0.91 to 0.99; 7 RCTs, 42,034 participants; moderate-certainty evidence). For every 1000 people treated with aspirin, 13 people would avoid death or dependency (number needed to treat for an additional beneficial outcome 79).

Authors' conclusions: Antiplatelet therapy with aspirin 160 mg to 300 mg daily, given orally (or by nasogastric tube or per rectum in people who cannot swallow) and started within 48 hours of onset of presumed ischaemic stroke, significantly decreased death and dependency, and reduced the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications; long-term outcomes were improved.

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Conflict of interest statement

JM: work as a health professional: NIHR Clinical Lecturer, University of Leicester. Affiliations: I am part of a topic group contributing to the 6th RCP National Clinical Guideline for Stroke. TC: work as a health professional: Clinical Fellow, Leicester, Northampton, Rutland Deanery. XW: grants and contracts: investigator grant, post‐doctoral fellowship, investigator grant development funding, NHMRC National Heart Foundation, NSW Health Commission. SB: work as health professional: previous work as a junior doctor in the stroke unit, University Hospitals Leicester, from August to December 2019. RC: none. MK: work as a health professional: NIHR Academic Clinical Fellow, University of Leicester. LB: work as a health professional: NIHR Clinical Lecturer, University of Leicester. TR: grants and contracts: National Lead, PACIFIC‐Stroke Trial, Population Health Research Institute, Hamilton, Canada (factor XIa inhibitor trial in acute ischaemic stroke). Work as health professional: Honorary Consultant Physician in Stroke Medicine, University Hospitals of Leicester NHS Trust: "As a health professional, I treat patients according to relevant national guidelines with antiplatelet therapy to reduce their risk of recurrent ischaemic stroke/TIA". Affiliations: Past President, British Association of Stroke Physicians: "I represent BASP on the Intercollegiate Stroke Working Party, which oversees the RCP National Clinical Guidelines for Stroke".

Figures

1
1
Flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
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4
Funnel plot of comparison: 1 Antiplatelet agent versus control in acute presumed ischaemic stroke, outcome: 1.1 Death or dependence at end of follow‐up.
5
5
Funnel plot of comparison: 1 Antiplatelet agent versus control in acute presumed ischaemic stroke, outcome: 1.2 Deaths from all causes during treatment period.
1.1
1.1. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 1: Death or dependence at end of follow‐up
1.2
1.2. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 2: Deaths from any cause during treatment period
1.3
1.3. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 3: Deaths from any cause during follow‐up
1.4
1.4. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 4: Deep venous thrombosis during treatment period
1.5
1.5. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 5: Pulmonary embolism during treatment period
1.6
1.6. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 6: Recurrent ischaemic/unknown stroke during treatment period
1.7
1.7. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 7: Symptomatic intracranial haemorrhage during treatment period
1.8
1.8. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 8: Recurrent stroke/intracranial haemorrhage during treatment period
1.9
1.9. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 9: Major extracranial haemorrhage during treatment period
1.10
1.10. Analysis
Comparison 1: Antiplatelet drug versus control in acute presumed ischaemic stroke, Outcome 10: Complete recovery from stroke (post hoc)
See this image and copyright information in PMC

Update of

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