Acute Ischemic Stroke Drugs
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Transcript of Acute Ischemic Stroke Drugs
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Acute Ischemic
Stroke Drugs
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Platelet Function Under Aspirin, Clopidogrel,
and Both After Ischemic Stroke
CD63 expression reflecting the release of platelet lysosomes is consistentlyincreased after stroke and incompletely suppressed by treatment with aspirin,
clopidogrel, or both. The strong prolongation of CADP-CT under combined
aspirin and clopidogrel in a patient subgroup may indicate a lower risk of
thrombosis but also a higher risk of hemorrhage
Combined antiplatelet agents may offer additive protection over single drugs
after stroke. We investigated whether platelet activation is reduced under
combined aspirin and clopidogrel compared with each drug alone
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A New Approach to Antithrombotic Therapy Evaluation of
Combined Therapy of Thromboxane Synthetase Inhibitor and
Very Low Dose of Aspirin
A very low dose of aspirin enhances the ability of OKY-046 toinhibit platelet aggregation and this combination therapy (OKY-
046 100 mg and a very low dose of aspirin which inhibits platelet
cyclooxygenase activity approximately 50%) may be of value as a
new approach to antithrombotic therapy
The effect of a selective thromboxane (TX) synthetase inhibitor (OKY-046),
alone and in combination with a very low dose of aspirin, on the platelet
function was studied in healthy and diseased subjects
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A Randomized Trial of Aspirin or Heparin In
Hospitalized Patients With Recent Transient
Ischemic Attacks
No significant difference between aspirinand heparin treatment in preventing
recurrent TIAs or cerebral infarction
compared the efficacy of temporary anticoagulation with intravenous heparin sodium
to the efficacy of aspirin in preventing cerebral infarction in
hospitalized patients with recent (
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Antiplatelet Effect of Aspirin in Patients
With Cerebrovascular Disease
There is a significant percentage of patients taking ASA
have no detectable antiplatelet effect using the PFA-100
test. This lack of effect was most common in patients
taking low-dose ASA or an enteric-coated ASA
preparation
Aspirin is used commonly to prevent ischemic strokes and other vascular events.
Although aspirin is considered safe and effective, it has limited efficacy with a relative
risk reduction of 20% to 25% for ischemic stroke. We sought to determine if aspirin as
currently used is having its desired antiplatelet effects
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Antiplatelet Therapy in Acute
Cerebral Ischemia
Antiplatelet drugs represent a diverse group of agents that share the ability toreduce platelet activity through a variety of mechanisms. Antiplatelet agents
such as aspirin may affect both NO and prostacyclin levels, their biological
activities go well beyond the platelet and include effects both locally on other
blood elements and within the vessel wall
Antiplatelet agents are a heterogenous class of drugs that have been successfully used
for more than2 decades in secondary stroke prevention. These agents include aspirin,
with or without dipyridamole, and more recently, the adenosine antagoniststiclopidine and clopidogrel
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Aspirin Effective in Males
Threatened with Stroke
The results indicate a clear and statistically significant risk reduction (19%, P < 0.05)
from aspirin. A second analysis, omitting the TIA endpoint, indicated a 31% risk
reduction in stroke or death from aspirin (P < 0.05). Sulfinpyrazone did not produce a
statistically significant risk reduction for either group of events, nor was there
significant synergism with, nor antagonism to, aspirin therapy.A 48% risk reduction {P
< 0.005) in stroke or death was found for male patients on aspirin but females did not
appear to benefit.
A CLINICAL TRIAL on 2 drugs which inhibit platelet function has been concluded after 5'/2 years
of cooperative effort. The results indicate that male patients threatened with stroke will benefit
by the daily use of the commonest and one of the oldest pharmaceutical agents aspirin.Females will not benefit and neither men nor women will benefit from the use of sulfinpyrazone
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Aspirin Inhibits p44/42 Mitogen-Activated Protein
Kinase and Is Protective Against
Hypoxia/Reoxygenation Neuronal Damage
ASA is neuroprotective against H/R damage partially by inhibitingthe ERK signaling pathway. When one considers previous reports
on the neuroprotective mechanisms of ASA, the combination of
multiple pharmacological activities and sites of action may explain
the beneficial effects of ASA on patients with high stroke risk
Acetylsalicylic acid (ASA) is preventive against stroke and protects against focal brain
ischemia in rats. We studied the mechanisms of the manner in which ASA provides
neuroprotection against hypoxia/reoxygenation (H/R) injury
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Aspirin Plus Dipyridamole Versus Aspirin for
Prevention of Vascular Events After Stroke or TIA
The combination of aspirin plus dipyridamole is more effective than aspirinalone in preventing stroke and other serious vascular events in patients with
minor stroke and TIAs. The risk reduction was greater and statistically
significant for studies using primarily extended release dipyridamole, which
may reflect a true pharmacological effect or lack of statistical power in studies
using immediate release dipyridamole
This meta-analysis systematically reviewed randomized controlled trials comparing
aspirin plus dipyridamole with aspirin alone in patients with stroke and TIA to
determine the efficacy of these agents in preventing recurrent cerebral and systemicvascular events
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Aspirin Response and Failure in
Cerebral Infarction
How the inhibition of platelet aggregation relates to stroke prevention remains unclear.The ability of aspirin and the dose required to inhibit platelet aggregation may depend
upon the individual. The results of the present study suggest that noncompliance is
rare and that certain individuals develop a biological effect of ASA (inhibition of
platelet aggregation) at a different but greater ASA dose and that others may never
respond in this manner to ASA
The purpose of this study was to assess the biological effect of aspirin as
measured by the inhibition of platelet aggregation in patients taking aspirin
for stroke prevention and in patients with acute stroke
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Aspirin Use and Incident Stroke in
the Cardiovascular Health Study
These analyses of the CHS cohort in which aspirin use was largely self-determinedsuggest that the regular use of aspirin may be associated with increased risk of stroke,
both ischemic and hemorrhagic, in older women. Among men, those with recognized
cardiovascular disease who used aspirin had lower rates of stroke than nonusers of
aspirin, while those who were aspirin users without cardiovascular disease had slightly
higher rates, but none of these findings were statistically significant
Randomized clinical trials testing aspirin in relatively low-risk, middle-aged people have
consistently shown small increases in stroke associated with aspirin use. We analyzed the
relationship between the regular use of aspirin and incident ischemic and hemorrhagic strokeamong people aged 65 years or older participating in the Cardiovascular Health Study
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Aspirin Versus Low-Dose Low-Molecular-Weight
Heparin: Antithrombotic Therapy in Pediatric
Ischemic Stroke Patients
This multicenter follow-up study provides evidence that drug-
related side effects were rare in both treatment arms and that
low-dose LMWH is not superior to medium dose aspirin or vice
versa as recurrent stroke prophylaxis in white pediatric patients
We sought to compare different antithrombotic secondary treatments (mainly
medium-dose aspirin with low-dose low-molecular-weight heparin [LMWH]) in
pediatric patients with a first ischemic stroke onset with regard to the risk of strokerecurrence
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Benefit of Clopidogrel Over Aspirin Is
Amplified in Patients With a History of
Ischemic Events
Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events(CAPRIE) patients with a history of prior symptomatic
atherosclerotic disease had a high rate of subsequent ischemic
events. The absolute benefit of clopidogrel over ASA seemed to
be amplified in such high-risk patients
The goal of this study was to examine the influence of preexisting symptomatic
atherosclerotic disease on subsequent ischemic event rates and compare the efficacy
of clopidogrel versus aspirin (acetylsalicylic acid, ASA) in patients with such disease
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Biological Assessment of Aspirin Efficacy
on Healthy Individuals
Our findings suggest that full resistance of healthy subjects to aspirin is ratherunlikely. However, differences in aspirin absorption, or pharmacokinetic, or
other unrecognized factors may lead to lack of effect of low dose of aspirin in
some subjects when using tests like platelet function analyzer-100. Whether
Cox polymorphisms are thrombotic risk factor for patients under aspirin will
require further research
The widespread use of aspirin requires clarification of the aspirin resistance
phenomenon. Most studies on this field are focused on patients which may
affect the action of aspirin
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Cerebral Hemorrhagic Risk of Aspirin or
Heparin Therapy With Thrombolytic
Treatment in Rabbits
Aspirin antiplatelet therapy alone may increasethe risk of hemorrhagic infarction, whereas
heparin or tissue plasminogen activator therapy
appears to be relatively safe
We studied the incidence of cerebral hemorrhage in an animal model of
embolic stroke to determine the safety of aspirin, heparin, and tissue
plasminogen activator therapies
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Combination Therapy With Low-Dose Aspirin
and Ticlopidine in Cerebral Ischemia
Platelet survival was prolonged and platelet lysis was reduced after treatment with
aspirin plus ticlopidine despite the fact that neither measure of platelet function was
significantly altered after treatment with aspirin alone or ticlopidine alone.
On the other hand, hemorrhagic complications were observed more frequently among
patients treated with aspirin plus ticlopidine than among those treated with aspirin
alone or ticlopidine alone. Our results indicate that the combination of aspirin plus
ticlopidine is a potent antiplatelet strategy
We compared combination therapy with low-dose aspirin plus ticlopidine to
therapy with aspirin alone or ticlopidine alone in patients suffering transient
ischemic attack or cerebral infarction
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Combining Aspirin With Oral Anticoagulant Therapy
Is This a Safe and Effective Practice in Patients With
Atrial Fibrillation?
The combination therapy of aspirin with either ximelagatran or warfarin did not reduce
the risk of stroke, systemic embolism, or myocardial infarction, but the addition of
aspirin to warfarin or ximelagatran was associated with increased risk of bleeding,
which was especially obvious when aspirin and warfarin were combined. Similar to the
combination of aspirin plus clopidogrel, the combination of an antiplatelet agent and
an oral anticoagulant in stroke patients seems to increase the risk of intracranial
hemorrhage
The Stroke Prevention Using an ORal Thrombin Inhibitor in atrial Fibrillation
(SPORTIF) investigators studied the risks and benefits of combining aspirinwith oral anticoagulant therapy in patients with AF
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Comparison of Triflusal and Aspirin for
Prevention of Vascular Events in Patients After
Cerebral Infarction
This study failed to show significantly superior efficacy of triflusalover aspirin in the long-term prevention of vascular events after
stroke, but triflusal was associated with a significantly lower rate
of hemorrhagic complications
The efficacy of the antiplatelet agent triflusal for prevention of vascular
events after stroke has been reported in a pilot study. However, there is a
need to confirm those results in a larger study
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Differences in Medical and Surgical Therapy for
Stroke Prevention Between Leading Experts in
North America and Western Europe
This analysis shows significant differences in several areas of strokeprevention practices between leading experts from NA and WE. Aspirin was
the first-choice antiplatelet agent in patients with a recent TIA or minor stroke
in both groups, recommended doses varied significantly. aspirin doses of 500
mg daily are given exclusively by American participants (36%), whereas doses
,200 mg are recommended only in Europe (51%)
The purpose of this analysis was to provide an informative and comparative view of
the current practice of leading experts in North America (NA) and Western Europe
(WE), where most of the large prevention trials have been performed
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Effect of Aspirin and Warfarin Therapy in
Stroke Patients With Valvular Strands
While on medical therapy, valvular strands do not significantlyincrease recurrent adverse event rates in patients with ischemic
stroke. Furthermore, the study does not provide evidence to
support an advantage of warfarin or aspirin for this purpose
Valvular strands are associated with ischemic stroke. The recurrent rate of adverse
events in stroke patients with valvular strands has not been defined and, importantly,
there are no randomized studies to evaluate efficacy of antithrombotic therapies inthese patients
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Effects of Clopidogrel and Aspirin in Combination Versus
Aspirin Alone on Platelet Activation and Major Receptor
Expression in Patients After Recent Ischemic Stroke
Treatment with clopidogrel with aspirin (C+ASA) for 1 monthprovides significantly greater inhibition of platelet activity than
ASA alone in patients after recent ischemic stroke in the frame of
the small randomized trial
To determine whether clopidogrel with aspirin (C+ASA) will produce more potent
platelet inhibition than aspirin alone (ASA) in patients after ischemic stroke, we
conducted the Plavix Use for Treatment of Stroke trial
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Effects of Fixed Low-Dose Warfarin, Aspirin-Warfarin
Combination Therapy, and Dose-Adjusted Warfarin
on Thrombogenesis in Chronic Atrial Fibrillation
Moreover, the introduction of 300 mg aspirin plus low-dose warfarin (1 mg/d),
low-dose warfarin alone (2 mg/d), or 300 mg aspirin plus low-dose warfarin (2
mg/d) did not significantly reduce any of the hemostatic markers studied
(except PAI-1 levels), whereas conventional full-dose warfarin (INR 2.0 to 3.0)
significantly reduced levels of fibrin D-dimer and fibrinogen
To determine whether introduction of fixed low-dose warfarin alone or in combination with
aspirin (300 mg) could normalize hemostatic markers, namely plasma fibrin D-dimer (an index of
thrombogenesis), plasminogen activator inhibitor-1 (PAI-1, an index of fibrinolysis), fibrinogen,
and von Willebrand factor (vWf, an index of endothelial dysfunction), in a manner comparableto adjusted-dose warfarin (target INR 2.0 to 3.0)
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Effects of Low-to-High Doses of Aspirin on
Platelet Aggregability and Metabolites of
Thromboxane A2 and Prostacyclin
Different doses of aspirin may be necessary to prevent thrombogenesisinduced by different triggers of different strengths and that 40 mg/day aspirin
is able to inhibit a large proportion of maximum thromboxane A2 release
provoked acutely, with the prostaglandin I2 synthesis being little affected;
however, higher doses of aspirin are required to attain further inhibition
The purpose of this study was to compare the effects of low-to-high doses of
aspirin on platelet aggregability determined by different methods and on the
metabolism of thromboxane A2 and prostacyclin
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Efficacy of Ticlopidine and Aspirin for Prevention of
Reversible Cerebrovascular Ischemic Events
The results in this subgroup of patients with reversible
ischemic disease, as well as the overall analysis of TASS,
suggest that ticlopidine is a more effective agent than
aspirin for the prevention of recurrent transient
ischemic attacks
This subgroup analysis from the Ticlopidine Aspirin Stroke Study (TASS) compared ticlopidine, a
new antiplatelet agent, with aspirin for the prevention of recurrent transient ischemic attacks in
patients who had a recent reversible cerebrovascular event
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Endothelial Cell Ischemic Injury: Protective Effect of
Heparin or Aspirin Assessed by
Scanning Electron Microscopy
This investigation illustrates an endothelial abnormality whichappears to be influenced by two pharmacological agents
considered possibly beneficial in preventing thromboembolic
phenomena related to heart attacks and strokes in man
The present study was undertaken to examine the effects of heparin and
aspirin in doses having significant antiplatelet aggregating activity
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Factors Associated With Ischemic Stroke
During Aspirin Therapy in Atrial Fibrillation
Postmenopausal estrogen replacement therapy
and moderate alcohol consumption may
additionally modify the risk of stroke in AF
Nonvalvular atrial fibrillation (AF) is a strong, independent risk factor for stroke, but the
absolute rate of stroke varies widely among AF patients, importantly influencing the potential
benefit of antithrombotic prophylaxis. We explore factors associated with ischemic stroke in AF
patients taking aspirin
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Increased Platelet Sensitivity to Collagen in
Individuals Resistant to Low-Dose Aspirin
ASA resistance may be caused by an increased sensitivity ofplatelets to collagen. A platelet aggregation study specific for
collagen dose response may be useful for strict selection of ASA
responders for low-dose ASA therapy and for identifying ASA
nonresponders for high-dose ASA therapy
The purpose of this study was to assess individual differences in the pharmacological
effects of acetylsalicylic acid (ASA) on bleeding time as measured by in vitro platelet
aggregation and to examine the consistency of responses over time
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Indications for Early Aspirin Use
in Acute Ischemic Stroke
Early aspirin is of benefit for a wide range of patients, and its prompt useshould be routinely considered for all patients with suspected acute ischemic
stroke, mainly to reduce the risk of early recurrence. No strong
contraindications are apparent and that hemorrhagic stroke can be excluded
with reasonable probability (with or without prior CT scan)
Starting daily aspirin promptly in patients with suspected acute ischemic stroke also reduces the
immediate risk of further stroke or death in hospital and the overall risk of death or dependency.
However, some uncertainty remains about the effects of early aspirin in particular categories of
patient with acute stroke
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Low-Dose Aspirin for Prevention of Stroke in
Low-Risk Patients With Atrial Fibrillation
For prevention of stroke in patients with NVAF,
aspirin at 150 to 200 mg per day does not seem
to be eithereffective or safe
We examined the efficacy and safety of aspirin therapy in
Japanese patients with nonvalvular atrial fibrillation (NVAF) in a
prospective randomized multicenter trial
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Nonaspirin Nonsteroidal Anti-inflammatory
Drugs and Hemorrhagic Stroke Risk
No increased risk of HS either subarachnoid
hemorrhage or intracerebral hemorrhage was
found among NANSAIDs users
The relationship between nonaspirin nonsteroidal anti-inflammatory drugs
(NANSAIDs) and hemorrhagic stroke (HS) remains unclear. We examined the risk of HS
associated with the use of NANSAIDs in Koreans
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Platelet Aggregation in Patients With Atrial
Fibrillation Taking Aspirin or Warfarin
Aspirin at the dosage used in the SPAF study (325 mg/d) did not completelyinhibit platelet aggregation in all patients. the presence of hyperaggregable
platelets in warfarin-treated patients and lack of complete inhibition of
platelet aggregation in aspirin-treated patients may be related to medication
failure in these patients.
The purpose of this study was to determine inhibition of platelet aggregation
in patients on aspirin and platelet reactivity in those on warfarin in the
Stroke Prevention in Atrial Fibrillation study
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Previous Use of Aspirin and
Baseline Stroke Severity
No evidence that previous aspirin use hasany effect on the type and severity of
ischemic stroke at baseline or on the
outcome at 6 months
Some studies suggest that taking aspirin regularly at the time of the onset of stroke reduces
stroke severity. Other studies suggest the converse (ie, that previous aspirin therapy is
associated with greater stroke severity). We sought to examine this question among the patients
enrolled in the International Stroke Trial (IST)
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Prospective Study of Aspirin Use and
Risk of Stroke in Women
These prospective data indicate that women who take 1 to 6 aspirin per week have a
reduced risk of large-artery occlusive infarction, but those who use 15 or more aspirinper week have an increased risk of subarachnoid hemorrhage. This observational study
suggests benefits of aspirin for ischemic stroke with low frequency of use and hazards
for hemorrhagic stroke with high frequency of use, particularly among older or
hypertensive women. Thus, the effect on total stroke will depend on the dose of aspirin
and the distribution of stroke subtypes and risk factors in the population
In secondary prevention, aspirin reduces risk of ischemic stroke. In primary
prevention of stroke, however, the role of aspirin is uncertain, especially in
women
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Regular Aspirin-Use Preceding the Onset of Primary
Intracerebral Hemorrhage is an Independent
Predictor for Death
We observed poor short-term outcomes and increased mortality,probably attributable to rapid enlargement of hematomas, in the
subjects with ICH who had been taking regularly moderate doses
of aspirin (median 250 mg) immediately before the onset of the
stroke
The effect of preceding aspirin-use on outcome after ICH is poorly
investigated. We investigated short-term mortality and hematoma
enlargement in subjects with ICH to find the predictors for these outcomes
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Risk of Hemorrhagic Stroke With
Aspirin Use
Based on the rarity of hemorrhagic stroke risk, concerns aboutthis risk should not dissuade appropriate patients from using
low-dose aspirin. Choosing doses between 75 mg and 325 mg per
day provides an optimal benefit to risk relationship
This review provides an update of the available data to offer greater clarity
regarding the risks of aspirin with respect to hemorrhagic stroke, as well as
insights regarding patient selection to minimize the risk of this complication
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Risk of Intracerebral Hemorrhage in Patients With
Arterial Versus Cardiac Origin of Cerebral Ischemia
on Aspirin or Placebo
Our findings do not confirm the previous finding of an excess riskof ICH in patients with cerebral ischemia of arterial origin.
Therefore, it seems that having cerebral ischemia of arterial
origin by itself is not associated with an increased risk of ICH, but
only in combination with high-intensity anticoagulation
To determine whether this excess risk of ICH was due to the underlying disease
(cerebral ischemia of arterial versus cardiac origin) or whether it depended on the
antithrombotic regimen, we studied the risk of ICH in arterial versus cardiac origin ofcerebral ischemia in patients who received aspirin or no antithrombotic drugs
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Risks and Benefits of Oral Anticoagulation Compared
With Clopidogrel Plus Aspirin in Patients With Atrial
Fibrillation According to Stroke Risk
In this clinical trial, patients with a CHADS21 had a low risk ofstroke, yet still derived a modest (1% per year) but statistically
significant absolute reduction in stroke with OAC and had low
rates of major hemorrhage on OAC
Oral anticoagulation (OAC) was more efficacious than combined clopidogrel plus aspirin (CA) in
preventing vascular events in patients with atrial fibrillation. However, because OAC carries
important bleeding complications, risk stratification schemes have been devised to identify
patients for whom the absolute benefits of OAC exceed its risks
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Screening for Aspirin Responsiveness After
Transient Ischemic Attack and Stroke
The prevalence of apparent ASA nonresponsiveness was higher with both the
POC tests than with LTA. However, agreement between the tests was poor and
very few patients were ASA nonresponsive by all 3 tests. Aspirin
nonresponsiveness is therefore highly test-specific and large prospective
studies will be required to determine the prognostic value of each of the
separate tests
The availability of simple to use point-of-care (POC) platelet function testsnow potentially allows
aspirin nonresponsiveness to be identified in routine clinical practice. However, there are
veryfew data on whether the different tests produce consistent results. We therefore compared
2 POC tests (PFA-100 device and the Ultegra-RPFA [RPFA]) with conventional light transmissionaggregometry (LTA)
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Therapeutic Benefit Aspirin Revisited in Light
of the Introduction of Clopidogrel
Aspirin is preferred for the majority of stroke or myocardial infarction patients
at risk of recurrent atherothrombotic events. Clopidogrel may, however,
provide valuable therapeutic benefit over aspirin in patients with peripheral
arterial disease and in stroke or myocardial infarction patients for whom
aspirin treatment is contraindicated or for whom aspirin fails to achieve the
desired therapeutic effect
Whether to switch from the well-established practice of recommending aspirin for use
in patients with atherothrombotic disease, both aspirin and clopidogrel are compared
with respect to the primary factors that influence such decisions
Thi idi A i i P S k
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Thienopyridines or Aspirin to Prevent Stroke
and Other Serious Vascular Events in Patients
at High Risk of Vascular Disease?
The thienopyridines appear modestly more effective than aspirin
in preventing serious vascular events in high-risk patients.Clopidogrel appears to be safer than ticlopidine and as safe as
aspirin, making it an appropriate, but more expensive,
alternative antiplatelet drug for patients unable to tolerate
aspirin
Aspirin is the most widely studied and prescribed antiplatelet drug for patients at high
risk of vascular disease. We aimed to establish how the thienopyridines (ticlopidine
and clopidogrel) compare with aspirin in terms of effectiveness and safety
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Ticlopidine Versus Aspirin for the
Prevention of Recurrent Stroke
Ticlopidine is somewhat more effective thanaspirin for reducing the risk of stroke in patients
with a completed minor stroke
We therefore performed an analysis on a subgroup of patients
from the Ticlopidine Aspirin Stroke Study (TASS) with a recent
minor completed stroke as the qualifying ischemic event
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Use of Aspirin, Epistaxis, and Untreated Hypertension as Risk
Factors for Primary Intracerebral Hemorrhage in Middle-Aged
and Elderly People
Epistaxis is a risk factor for ICH in middle-aged and elderly
people, both independently and combined with the use ofaspirin. Other independent risk factors are untreated
hypertension, previous ischemic stroke, epilepsy, and recent
strenuous physical exertion. Epistaxis may be a warning sign of
an increased risk for ICH in subjects using aspirin
The incidence of primary intracerebral hemorrhage (ICH) increases exponentially with
age, but the risk factors are not well known. We investigated lifestyle factors, previous
diseases, and medications as risk factors for ICH in middle-aged and elderly people
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Clopidogrel-Associated TTP
Clopidogrel-associated TTP often occurs within 2 weeks
of drug initiation, occasionally relapses, and has a high
mortality if not treated promptly
This study assessed the completeness of information on TTP diagnosis,
treatment response, and causality from the 3 reporting systems. In addition,
predictors of mortality were identified through classification tree analysis.
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The Risks and Safety of Clopidogrel in
Pediatric Arterial Ischemic Stroke
Clopidogrel to be relatively well tolerated in thepediatric population. In combination with aspirin
and in the presence of other risk factors,
intracranial bleeding may be seen
The purpose of this study was to determine safety and tolerability of clopidogrel in
children with arterial ischemic stroke (AIS). Clopidogrel is the alternative antiplatelet
medication when aspirin is not tolerated or fails
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