 |
 |
|
Home |
Current Issue |
Past Issues |
In the Clinic |
ACP Journal Club |
CME |
Collections |
Audio/Video |
Mobile |
Subscribe |
Tools |
Help |
ACP Online
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1 July 1994 | Volume 121 Issue 1 | Pages 41-53
Purpose: To review the effectiveness of medical treatments for stroke prevention in patients at elevated risk for stroke.
Data Sources: English-language articles published after 1977 and indexed in MEDLINE under the following Medical Subject Heading terms: anticoagulants, aspirin, dipyridamole, ticlopidine, or sulfinpyrazone, combined with cerebrovascular disorders.
Study Selection: Randomized controlled trials of anticoagulant or platelet antiaggregant treatment reporting subsequent stroke and myocardial infarction, death, or complications in persons with asymptomatic carotid stenosis or bruit, transient ischemic attack (TIA), previous stroke, nonvalvular atrial fibrillation, or other vascular diseases.
Data Extraction: Of 900 articles identified, 33 were selected by two independent reviewers and abstracted for outcome events and person-years of follow-up.
Results: In patients with nonvalvular atrial fibrillation, warfarin is highly effective in reducing stroke and death but may result in more complications. Aspirin appears to be less effective and less risky than anticoagulation. In patients with TIA or minor stroke, both aspirin and ticlopidine reduce the risk for stroke. In patients who have had myocardial infarction, warfarin is effective but had high complication rates in the reviewed studies. Aspirin slightly reduces the risk for stroke.
Conclusions: Warfarin is strongly recommended for persons with nonvalvular atrial fibrillation who are older than 60 years or who have additional risk factors for stroke. Aspirin is recommended for persons at elevated risk for bleeding while receiving anticoagulants. For persons with TIA or minor stroke, aspirin should be used first. Patients who do not respond to or tolerate aspirin or who have had a major stroke are reasonable candidates for ticlopidine. For patients who have had myocardial infarction, aspirin is recommended for the prevention of secondary myocardial infarction but not of stroke.
Author and Article Information
From Duke University and Durham Veterans Affairs Medical Center, Durham, North Carolina; the University of Western Ontario, London, Ontario, Canada.
REVIEW
Medical Treatment for Stroke Prevention
Requests for Reprints: David B. Matchar, MD, Center for Health Policy Research and Education, Duke University, P.O. Box 90253, Durham, NC 27708.
Acknowledgments: The authors thank Vic Hasselblad, PhD, John Pauk, MD, Pam Duncan, PhD, Greg Samsa, PhD, Emilia Richichi, PhD, Fikri Yucel, and Samantha Mackey for technical assistance; Annette Jurgelski for editorial assistance; and Kathy Malone and Sandy Thomas for manuscript preparation.
This article has been cited by other articles:
|
|
 |
|
  G.Q. Villani, M. Piepoli, P.E. Villani, and A. Capucci Anticoagulation in atrial fibrillation: what is certain and what is to come Eur. Heart J. Suppl., September 1, 2003; 5(suppl_H): H45 - H50. [Abstract] [PDF]
|
|
|
|
 |
|
 D. J. Brauner, J. C. Muir, and G. A. Sachs Treating Nondementia Illnesses in Patients With Dementia JAMA, June 28, 2000; 283(24): 3230 - 3235. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. P. Samsa, D. B. Matchar, L. B. Goldstein, A. J. Bonito, L. J. Lux, D. M. Witter, and J. Bian Quality of Anticoagulation Management Among Patients With Atrial Fibrillation: Results of a Review of Medical Records From 2 Communities Arch Intern Med, April 10, 2000; 160(7): 967 - 973. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. B. Gorelick, R. L. Sacco, D. B. Smith, M. Alberts, L. Mustone-Alexander, D. Rader, J. L. Ross, E. Raps, M. N. Ozer, L. M. Brass, et al. Prevention of a First Stroke: A Review of Guidelines and a Multidisciplinary Consensus Statement From the National Stroke Association JAMA, March 24, 1999; 281(12): 1112 - 1120. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. W. Albers Choice of Antithrombotic Therapy for Stroke Prevention in Atrial Fibrillation: Warfarin, Aspirin, or Both? Arch Intern Med, July 27, 1998; 158(14): 1487 - 1491. [Full Text] [PDF]
|
|
|
|
 |
|
 B. F. Gage, A. B. Cardinalli, and D. K. Owens Cost-Effectiveness of Preference-Based Antithrombotic Therapy for Patients With Nonvalvular Atrial Fibrillation Stroke, June 1, 1998; 29(6): 1083 - 1091. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Parmigiani, G. P. Samsa, M. Ancukiewicz, J. Lipscomb, V. Hasselblad, and D. B. Matchar Assessing Uncertainty in Cost-Effectiveness Analyses: Application to a Complex Decision Model Med Decis Making, October 1, 1997; 17(4): 390 - 401. [Abstract] [PDF]
|
|
|
|
|
|
L. B. Goldstein, A. Farmer, and D. B. Matchar Primary Care Physician–Reported Secondary and Tertiary Stroke Prevention Practices : A Comparison Between the United States and the United Kingdom Stroke, April 1, 1997; 28(4): 746 - 751. [Abstract] [Full Text]
|
|
|
|
 |
|
 M. Guffi, J. Bogousslavsky, X. Jeanrenaud, G. Devuyst, and H. Sadeghi SURGICAL PROPHYLAXIS OF RECURRENT STROKE IN PATIENTS WITH PATENT FORAMEN OVALE: A PILOT STUDY J. Thorac. Cardiovasc. Surg., August 1, 1996; 112(2): 260 - 263. [Abstract] [Full Text]
|
|
|
|
|
|
R. G. Hart and M. J.G. Harrison Aspirin Wars : The Optimal Dose of Aspirin to Prevent Stroke Stroke, April 1, 1996; 27(4): 585 - 587. [Full Text]
|
|
|
|
|
|
H.J.M. Barnett, M. Kaste, H. Meldrum, and M. Eliasziw Aspirin Dose in Stroke Prevention : Beautiful Hypotheses Slain by Ugly Facts Stroke, April 1, 1996; 27(4): 588 - 592. [Full Text]
|
|
|
|
|
|
L. B. Goldstein, A. J. Bonito, D. B. Matchar, P. W. Duncan, G. H. DeFriese, E. Z. Oddone, J. E. Paul, D. R. Akin, and G. P. Samsa US National Survey of Physician Practices for the Secondary and Tertiary Prevention of Ischemic Stroke : Design, Service Availability, and Common Practices Stroke, September 1, 1995; 26(9): 1607 - 1615. [Abstract] [Full Text]
|
|
|
|
 |
|
 D.B. Cines and M. Laposata Case 15-1995- A 70-year-old woman with atrial fibrillation and the rapid onset of hemorrhagic manifestations N. Engl. J. Med., May 18, 1995; 332(20): 1363 - 1370. [Full Text] [PDF]
|
|
|
|
|
|
H. J.M. Barnett, M. Eliasziw, and H. E. Meldrum Drugs and Surgery in the Prevention of Ischemic Stroke N. Engl. J. Med., January 26, 1995; 332(4): 238 - 248. [Full Text] [PDF]
|
|
Article
