Prevention of Stroke: Antithrombotic Treatments for CAD Have Similar Outcomes

Among patients with cervical artery dissection (CAD), there are no significant differences between anticoagulants and antiplatelets in the prevention of stroke, according to study results published in JAMA Neurology.

Researchers conducted a systematic review and individual patient data meta-analysis to compare anticoagulant and antiplatelet therapies in prevention of stroke after CAD.

The researchers looked at publication databases through August 2023 for randomized clinical trials (RCTs) that assessed the efficacy and safety antithrombotic treatments in patients with CAD.

The primary outcome for the meta-analysis was a composite of ischemic stroke, death, or major extracranial or intracranial bleeding at 90 days of follow-up. Each component of the composite primary outcome was assessed individually as secondary outcomes. Logistic regression was used in analyses.

Two RCTs were identified for inclusion: Cervical Artery Dissection in Stroke Study (CADISS) and Cervical Artery Dissection in Stroke Study and the Biomarkers and Antithrombotic Treatment in Cervical Artery Dissection (TREAT-CAD).

The CADISS study was a phase 3 feasibility trial conducted in Australia between February 2006 and June 2013 that compared the efficacy of anticoagulants and antiplatelets in preventing recurrent stroke among 250 patients with CAD.

The TREAT-CAD study was a multicenter, randomized, noninferiority trial conducted in Denmark, Germany, and Switzerland between September 2013 and December 2018 that compared the efficacy of aspirin vs anticoagulants in preventing a composite of clinical outcomes (ischemic stroke, major extracranial or intracranial hemorrhage, and mortality) among 194 patients with CAD.

The intention-to-treat (ITT) population comprised 444 patients (median age, 48; men, 67%; affected internal carotid artery, 55.9%; ischemic cerebral event at baseline, 87.6%), 226 (50.9%) of whom received antiplatelet therapy and 218 of whom received anticoagulation therapy.

A total of 370 patients were included in the per-protocol population. In the pooled study population, 192 of whom received antiplatelet therapy and 178 of whom received anticoagulation therapy.

The primary outcomes occurred in 10 (4.4%) patients in the antiplatelet group and 3 (1.4%) patients in the anticoagulation group. There was no significant difference in the primary endpoint on the ITT analysis (odds ratio [OR], 0.33; 95% CI, 0.08-1.05; P =.06). The findings were similar in the per-protocol population (OR, 0.35; 95% CI, 0.09-1.09; P =.07).

Of the 10 ischemic strokes documented, 9 occurred in the antiplatelet group and 1 occurred in the anticoagulation group. Two cases of major bleeding occurred in the anticoagulation group and no cases occurred in the antiplatelet group. While anticoagulation treatment was linked to a reduced risk for ischemic stroke (OR, 0.14; 95% CI, 0.02-0.61; P =.01), there was no significant difference between the 2 groups regarding major bleeding (OR, 5.23; 95% CI, 4.22-723.08; P =.22). Additionally, there were no deaths in either group.

The primary limitation of this study was the small sample size, which resulted in the inability to identify smaller, but clinically meaningful differences.

“Our results suggest further large RCTs in [sic] with regard to anticoagulant use are required,” the researchers concluded.

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.