Antiplatelet agents in stroke prevention

Summary

In primary prevention, aspirin reduces the risk of stroke but not of myocardial infarction in women while in men only the risk of myocardial infarction but not stroke could be significantly reduced. Only aspirin has been shown to be safe and effective in large randomized trials in the first 48 hours after ischemic stroke. Aspirin/dipyridamole and clopidogrel both reduce the risk of a combined cardiovascular outcome in long-term secondary prevention compared to aspirin alone. More potent antiplatelet drugs or combination of aspirin and clopidogrel prevent more ischemic events, but also lead to more bleeding complications. No benefit of oral anticoagulants could be shown in patients with non-cardioembolic stroke. In patients with atrial fibrillation oral anticoagulation is more effective than aspirin in stroke prevention. The choice between oral anticoagulants and aspirin in these patients depends on age and the individual risk factor profile. Patients with symptomatic intracranial stenosis have a higher risk of intracerebral bleeding with oral anticoagulation compared to high dose aspirin. Aspirin is the recommended treatment in stroke patients with a patent foramen ovale.

Zusammenfassung

Aspirin ist in der Schlaganfall-Primärprophylaxe bei Frauen wirksam, während es bei Männern zwar das Herzinfarktrisiko, aber nicht signifikant das Schlaganfallrisiko senkt. Bisher wurde nur für Aspirin ein Nutzen in der Akutbehandlung (erste 48 Stunden) des ischämischen Schlaganfalles nachgewiesen. Sowohl die Kombination Aspirin/Dipyridamol als auch Clopidogrel sind in der Verhinderung kardiovaskulärer Ereignisse wirksamer als eine Aspirin-Monotherapie. Potentere Thrombozytenfunktionshemmer oder die Kombination Aspirin/Clopidogrel können zwar mehr ischämische Ereignisse verhindern, sind aber mit einem deutlich höheren Blutungsrisiko bei Schlaganfallpatienten behaftet. Bei Patienten mit einem nicht kardioembolischen Schlag -anfall sind Thrombozytenfunktionshemmer einer oralen Antikoagulation aufgrund eines geringeren Blutungsrisikos vorzuziehen. Die orale Antikoagulation ist bei nachgewiesenem Vorhofflimmern in der Schlaganfallprävention wirksamer als Thrombozytenfunktionshemmer und sollte anhand des Lebens-alters und dem individuellen Risikoprofil erfolgen. Aspirin ist sowohl bei Schlaganfallpatienten mit intrakraniellen Stenosen als auch bei einem nachgewiesenen offenen Foramen ovale das Mittel der ersten Wahl.

Keywords

Ischaemic stroke - transient ischaemic attack - antiplatelet - primary prevention - secondary prevention - anticoagulation

Schlüsselwörter

Schlüsselwörter Ischämischer Schlaganfall - transiente ischämische Attacke - Thrombozytenfunktions -hemmer - Primärprävention - Sekundärprävention - Antikoagulation

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