Stroke Alert: A Review of Current Clinical Stroke Literature
By Matthew E. Fink, MD, Professor and Chairman, Department of Neurology, Weill Cornell Medical College, and Neurologist-in-Chief, New York Presbyterian Hospital
Clopidogrel Added to Aspirin Reduces Ischemic Stroke Risk after TIA or Minor Stroke
Sources:Wang Y, et al. for the CHANCE Investigators. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. New Engl J Med 2013;369:11-19.
Hankey G. Dual antiplatelet therapy in acute transient ischemic attack and minor stroke. Editorial. New Engl J Med 2013;369:82-83.
Stroke commonly occurs during the first few weeks or months after a transient ischemic attack (TIA) or minor stroke, and the investigators of the CHANCE trial (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events) tested the potential benefits and risks of adding clopidogrel to aspirin to provide greater protection against subsequent stroke than aspirin alone. In a randomized, double-blind, placebo-controlled trial at 114 centers in China, 5170 patients were randomly assigned within 24 hours of the acute event to either aspirin at 75 mg per day plus placebo for 90 days or clopidogrel (initial dose of 300 mg followed by 75 mg per day for 90 days) plus aspirin at a dose of 75 mg per day for the first 21 days. The primary outcome was stroke (ischemic or hemorrhagic) during 90 days of follow-up in an intention-to-treat analysis. Differences were assessed using a random-effects, Cox proportional-hazards model.
Stroke occurred in 8.2% of patients in the clopidogrel-aspirin group compared to 11.7% of those in the aspirin group (hazard ratio, 0.68; 95% confidence interval, 0.57-0.81; P < 0.001). Significant hemorrhage occurred in seven patients (0.3%) in the clopidogrel-aspirin group and in eight (0.3%) in the aspirin-alone group. Hemorrhagic stroke occurred in 0.3% in each group. The aspirin-clopidogrel group had a 32% reduction in risk of recurrent stroke at 90 days, compared to aspirin alone, with no increase in risk of hemorrhagic complications. However, it is premature to generalize these findings outside of the Chinese population, since there is a much higher rate of intracranial atherosclerosis in the Chinese population, and other associated risk factors (hypertension, smoking, hyperlipidemia) occur at different frequencies than in North America and Europe.
Stroke Alert: A Review of Current Clinical Stroke Literature
Women Are at Greater Risk of Dying from Stroke Than Men
Source: Zhou G, et al. Sex differences in stroke case fatality: A meta-analysis. Acta Neurol Scand 2013;128:1-8.
There is ongoing controversy regarding gender disparity in stroke treatment and outcomes. Many small studies suggest that women have worse outcomes than men after stroke, and some authors have suggested that women are less likely to receive thrombolysis or other interventions than men. However, there is a dearth of large, population-based studies that have examined gender differences in treatment and outcome. Zhou et al investigated sex differences in stroke case fatality in all published studies based on a comprehensive meta-analysis. A systematic search of all published databases was made for papers published from 1992 through 2009, groups were pooled, and a random effects model was used to find sex differences in cases of fatality of stroke with a Mantel-Haenzel method. A meta-regression analysis was also performed.
Thirty six population-based studies, along with three randomized clinical trials (RCTs), representing 125,227 men and 115,511 women, were included and analyzed. For the pooled group, there was an overall hazard risk of 1.13 for women compared to men. In the RCTs subgroup, there was a hazard risk of 1.27 for women and in the population-based studies a risk of 1.12. Although these data support the hypothesis that stroke case fatality is higher in women, more large, multicenter clinical trials are needed to determine this with more certainty.
