Antiplatelet Therapy for Secondary Prevention of Lacunar Stroke | Journal Scan

Study Questions:

What is the efficacy of antiplatelet agents for secondary stroke prevention after a lacunar infarct?

Methods:

This was a systematic review and meta-analysis of randomized controlled trials of antiplatelet agents for secondary prevention of stroke and vascular events after lacunar stroke. The outcomes examined were: stroke (ischemic or hemorrhagic); ischemic stroke; and the composite outcome of stroke, myocardial infarction, or death.

Results:

There were 17 trials with 42,234 patients included in the analyses. When compared with placebo, any antiplatelet therapy was associated with a reduction in stroke (risk ratio [RR], 0.77; 95% confidence interval [CI], 0.62-0.97) and ischemic stroke (RR, 0.48; 95% CI, 0.30-0.78), but not the composite outcome (RR, 0.89; 95% CI, 0.75-1.05). There was no significant benefit to cilostazol, ticlopidine, dipyridamole, terutobran, or sarpogrelate when compared with aspirin for the outcomes of any stroke or the composite outcome. When aspirin was compared with dual antiplatelet therapy (aspirin plus dipyridamole, cilostazol, or clopidogrel) for any stroke, the dual antiplatelet therapy had a trend toward benefit (RR, 0.83; 95% CI, 0.68-1.00). There was no benefit to dual antiplatelet therapy for ischemic stroke (RR, 0.48; 95% CI, 0.30-0.78) or the composite outcome (RR, 0.89; 95% CI, 0.75-1.05). When clopidogrel monotherapy was compared with ticlopidine and dual antiplatelet therapy (dipyridamole plus aspirin and clopidogrel plus aspirin), there was no difference in any stroke or the composite outcome (RR, 0.91; 95% CI, 0.75-1.10; RR, 1.00; 95% CI, 0.78-1.28, respectively).

Conclusions:

The authors concluded that in patients with lacunar stroke, antiplatelet monotherapy is effective and should be used for secondary stroke prevention.

Perspective:

Lacunar strokes represent about 20% of all ischemic strokes and are thought to be due to small-vessel ischemic disease. Most of the secondary prevention data in this population come from subgroup analyses of larger trials. This study provides additional evidence for the role of antiplatelet monotherapy for secondary prevention of vascular events in patients with lacunar stroke. Dual antiplatelet therapy does not appear to benefit these patients. While the data do not directly support one antiplatelet agent over another, given aspirin’s low cost, tolerability, and known side effect profile, it can be considered the first-line agent for secondary prevention in patients with lacunar stroke.

Clinical Topics: Prevention, Vascular Medicine, Statins

Keywords: Stroke, Stroke, Lacunar, Myocardial Infarction, Secondary Prevention, Aspirin, Dipyridamole, Ticlopidine, Platelet Aggregation Inhibitors, Drug Combinations


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