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Acta Neurologica Taiwanica Sep 2023Antiplatelet therapy is the first-line management for noncardioembolic transient ischemic attack (TIA) and acute ischemic stroke (IS). Herein, we review the safety and... (Review)
Review
Antiplatelet therapy is the first-line management for noncardioembolic transient ischemic attack (TIA) and acute ischemic stroke (IS). Herein, we review the safety and efficacy of antiplatelet therapies in patients with IS and TIA, primarily focusing on the acute stage. We discuss current antiplatelet monotherapy and the factors influencing efficacy and continuation rate according to clinical trial data. Aspirin remains the most commonly used first-line antiplatelet agent for preventing noncardioembolic stroke recurrence, and clopidogrel, cilostazol, and ticagrelor are feasible alternatives. Various short-term dual antiplatelet therapies (including clopidogrel-aspirin and ticagrelor-aspirin combination therapy) for minor stroke and high-risk TIA are also reviewed. For selected patients with specific stroke etiologies, short-term dual antiplatelet therapy with aspirin combined with clopidogrel or ticagrelor can significantly reduce the risk of stroke. However, insufficient evidence supports the benefits of triple antiplatelet therapy for recurrent noncardioembolic stroke prevention, and this treatment substantially increases the rate of bleeding complications. Keyword: antiplatelet therapy, acute ischemic stroke, secondary prevention, transient ischemic attack.
Topics: Humans; Secondary Prevention; Platelet Aggregation Inhibitors; Ischemic Stroke; Ischemic Attack, Transient; Ticagrelor; Clopidogrel; Stroke; Cerebral Infarction; Aspirin
PubMed: 37674428
DOI: No ID Found -
VASA. Zeitschrift Fur Gefasskrankheiten Jul 2019Antiplatelet agents significantly reduce mortality and morbidity in ischemic heart disease, cerebrovascular disease and peripheral artery disease (PAD), and are... (Review)
Review
Antiplatelet agents significantly reduce mortality and morbidity in ischemic heart disease, cerebrovascular disease and peripheral artery disease (PAD), and are therefore part of guideline-driven daily medical treatment in these patients. Due to its beneficial effects in the secondary prevention of atherothrombotic events, aspirin remains the most frequently prescribed antiplatelet agent in cardiovascular disease. In patients with acute coronary syndromes (ACS) and in those undergoing angioplasty with stent implantation dual antiplatelet therapy with aspirin and an adenosine diphosphate (ADP) receptor antagonist is indicated. The development of the newer ADP P2Y inhibitors prasugrel and ticagrelor has further improved prognosis in ACS patients compared to clopidogrel. Moreover, vorapaxar allows the inhibition of platelet activation by thrombin via protease-activated receptor-1 and has been approved for the use in patients with PAD and in those with a history of myocardial infarction. This review article summarizes the current evidence on oral antiplatelet agents in cardiovascular disease. Aspirin, clopidogrel, prasugrel, ticagrelor, vorapaxar, cardiovascular disease.
Topics: Adenosine; Administration, Oral; Cardiovascular Diseases; Humans; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Ticlopidine
PubMed: 30324870
DOI: 10.1024/0301-1526/a000753 -
Current Cardiology Reviews 2021Dual antiplatelet therapy is one of the cornerstones of modern percutaneous coronary interventions. The development of new therapeutic agents has significantly reduced... (Review)
Review
Dual antiplatelet therapy is one of the cornerstones of modern percutaneous coronary interventions. The development of new therapeutic agents has significantly reduced ischemic events at the risk of increased bleeding complications. Therefore, efforts are currently focused on optimizing therapeutic algorithms to obtain the greatest anti-thrombotic benefit associated with the lowest risk of bleeding, that is, the greater net clinical benefit. A significant number of trials evaluating different drug combinations or adjustments in treatment duration have been completed. However, clinical translation of these results is often difficult due to the heterogeneity of the therapeutic approaches. The aim of this manuscript is to provide an updated review of the literature regarding the use of dual antiplatelet therapy in patients undergoing coronary angioplasty and stenting.
Topics: Humans; Percutaneous Coronary Intervention; Platelet Aggregation Inhibitors; Treatment Outcome
PubMed: 32538731
DOI: 10.2174/1573403X16666200615144423 -
Journal of Clinical Neuroscience :... Feb 2020Transient Ischaemic Attack (TIA) if untreated carries a high risk of early stroke and is associated with poorer long-term survival [1]. There is emerging evidence of a... (Review)
Review
Transient Ischaemic Attack (TIA) if untreated carries a high risk of early stroke and is associated with poorer long-term survival [1]. There is emerging evidence of a reduction in stroke risk following TIA. Time critical investigations and management, as well as service organisation remain key to achieving good outcomes. Patients are diagnosed with TIA if they have transient, sudden-onset focal neurological symptoms which usually completely and rapidly resolve by presentation. The tissue based definition of TIA guides the fact that patients with residual symptoms should be considered as potentially having a stroke, with urgent evaluation regarding eligibility for thrombolysis and/or endovascular clot retrieval (ECR). Essential investigations for all patients with TIA should include early brain imaging, ECG, and carotid imaging in patients with anterior circulation symptoms. After brain imaging, exclusion of high risk indicators and immediate administration of an antiplatelet agent, subsequent attention to other mechanistic factors can be managed safely as part of a structured clinical pathway supervised by stroke specialists. This is in line with the recently revised Stroke Foundation Clinical Guidelines for Stroke Management (2017).
Topics: Humans; Ischemic Attack, Transient; Male; Neuroimaging; Platelet Aggregation Inhibitors; Stroke
PubMed: 31911111
DOI: 10.1016/j.jocn.2019.12.032 -
Stroke Dec 2023This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral... (Review)
Review
This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75-0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97-2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients' predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25-1.03]; =0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.
Topics: Humans; Platelet Aggregation Inhibitors; Treatment Outcome; Cerebral Hemorrhage; Stroke; Fibrinolytic Agents; Anticoagulants
PubMed: 37916459
DOI: 10.1161/STROKEAHA.123.036886 -
Thrombosis Research Dec 2020The possibility of an acquired platelet function disorder should be considered in patients who present with recent onset muco-cutaneous bleeding. Despite the... (Review)
Review
The possibility of an acquired platelet function disorder should be considered in patients who present with recent onset muco-cutaneous bleeding. Despite the availability of newer and faster platelet function assays, light transmission aggregometry (LTA) remains the preferred diagnostic test. This review examines and discusses the causes of acquired platelet dysfunction; most commonly drugs, dietary factors, medical disorders and procedures. In addition to well-known antiplatelet therapies, clinicians should be alert for newer drugs which can affect platelets, such as ibrutinib. There is little clinical trial evidence to guide the management of acquired platelet function defects, but we summarise commonly employed strategies, which include addressing the underlying cause, antifibrinolytic agents, desmopressin infusions, and in selected patients, platelet transfusions.
Topics: Blood Platelet Disorders; Blood Platelets; Humans; Platelet Aggregation; Platelet Aggregation Inhibitors; Platelet Function Tests; Platelet Transfusion
PubMed: 31229273
DOI: 10.1016/j.thromres.2019.06.009 -
Methods in Molecular Biology (Clifton,... 2023In the late 1990s, the antithrombotic antiplatelet agent, clopidogrel, a P2Y12 inhibitor, was introduced. Around the same time, there was an increase in a number of new...
In the late 1990s, the antithrombotic antiplatelet agent, clopidogrel, a P2Y12 inhibitor, was introduced. Around the same time, there was an increase in a number of new methods to measure platelet function (e.g., PFA-100 in 1995), and this has continued. It became evident that not all patients responded to clopidogrel in the same way and that some patients had a relative "resistance" to therapy, termed "high on-treatment platelet reactivity." This then led to some publications to advocate platelet function testing being used for patients on antiplatelet therapy. Platelet function testing was also suggested for use in patients awaiting cardiac surgery after stopping their antiplatelet therapy as a way of balancing thrombotic risk pre-surgery and bleeding risk perioperatively. This chapter will discuss some of the commonly used platelet function tests used in these settings, particularly those that are sometimes referred to as point-of-care tests or that require minimal laboratory sample manipulation. The latest guidance and recommendations for platelet function testing will be discussed following several clinical trials looking at the usefulness of platelet function testing in these clinical settings.
Topics: Humans; Platelet Aggregation Inhibitors; Clopidogrel; Ticlopidine; Blood Platelets; Platelet Function Tests
PubMed: 37204725
DOI: 10.1007/978-1-0716-3175-1_25 -
Hamostaseologie 2016Since more than 20 years, aspirin is an approved and established first-line antiplatelet medication in cardiovascular prevention. This is partially due to ist unique... (Review)
Review
Since more than 20 years, aspirin is an approved and established first-line antiplatelet medication in cardiovascular prevention. This is partially due to ist unique mode of action which is not shared with any other antiplatelet agent as well by the reliability of its pharmacological efficacy: inhibition of platelet COX-1 and subsequent thromboxane formation in almost every patient. Aspirin acts synergistic with ADP-antagonists in dual antiplatelet therapy of acute coronary syndromes (ACS) and percutaneous coronary interventions (PCI) and is also approved for long-term secondary prevention. Patients with atrial fibrillation are an exception and benefit more from anticoagulants. After the introduction of the new oral anticoagulants (NOACs), i.e. direct inhibitors of factor Xa or thrombin formation, there is a renewed discussion about the role of antiplatelet agents, specifically if additional dual antiplatelet treatment is still necessary for an optimum clinical effect or whether one component, such as aspirin might be skipped in favor of other classes of oral antiplatelet agents, such as ADP-antagonists. The available data are insufficient to recommend this because of a low number of studies and a still uncertain benefit/risk (bleeding) ratio. More research on aspirin as a chemopreventive appears also to be necessary and is going on, in particular in individuals at high-risk for vascular thrombotic diseases (diabetics, preeclampsia, venous thromboembolism).
Topics: Anticoagulants; Aspirin; Dose-Response Relationship, Drug; Drug Administration Schedule; Evidence-Based Medicine; Fibrinolytic Agents; Humans; Platelet Aggregation Inhibitors; Thrombosis; Treatment Outcome
PubMed: 25891122
DOI: 10.5482/hamo-14-10-0048 -
The Lancet. Haematology Aug 2020Lifelong anticoagulation with warfarin or alternative vitamin K antagonist is the standard anticoagulant treatment for thrombotic antiphospholipid syndrome.... (Review)
Review
Lifelong anticoagulation with warfarin or alternative vitamin K antagonist is the standard anticoagulant treatment for thrombotic antiphospholipid syndrome. Anticoagulant-refractory thrombotic antiphospholipid syndrome can be broadly defined as breakthrough thrombosis while on standard oral anticoagulation treatment and its management is a major challenge given the serious nature of the thrombotic disease observed, which has become refractory to oral anticoagulation. The factors (genetic and cellular) that cause anticoagulant-refractory thrombotic antiphospholipid syndrome are now better understood. However, efforts to use this greater understanding have not yet transformed the capacity to treat it successfully in many patients. In this Viewpoint, we review the factors that are likely to be contributing to the cause of this syndrome and consider how they might be modified or inhibited. We also discuss management, including general strategies to minimise thrombotic risk, intensification of anticoagulation, addition of an antiplatelet agent, adjunctive treatment for thrombosis, immunomodulatory therapy, complement inhibition, vascular options, and future potential therapeutic targets.
Topics: Anticoagulants; Antiphospholipid Syndrome; Drug Resistance; Fibrinolytic Agents; Humans; Platelet Aggregation Inhibitors; Thrombolytic Therapy; Thrombosis
PubMed: 32735839
DOI: 10.1016/S2352-3026(20)30116-2 -
Arteriosclerosis, Thrombosis, and... Apr 2019Antiplatelet therapies are an essential tool to reduce the risk of developing clinically apparent atherothrombotic disease and are a mainstay in the therapy of patients... (Review)
Review
Antiplatelet therapies are an essential tool to reduce the risk of developing clinically apparent atherothrombotic disease and are a mainstay in the therapy of patients who have established cardiovascular, cerebrovascular, and peripheral artery disease. Strategies to intensify antiplatelet regimens are limited by concomitant increases in clinically significant bleeding. The development of novel antiplatelet therapies targeting additional receptor and signaling pathways, with a focus on maintaining antiplatelet efficacy while preserving hemostasis, holds tremendous potential to improve outcomes among patients with atherothrombotic diseases.
Topics: Atherosclerosis; Humans; Ischemia; Platelet Aggregation Inhibitors; Thrombophilia
PubMed: 30760019
DOI: 10.1161/ATVBAHA.118.310955