Antiplatelet Therapy in Ischemic Stroke and Transient Ischemic Attack: A Network Meta-Analysis of Randomized Controlled Trials
Aisha Rizwan Ahmed1, Mrinal Murali Krishna2, Meghna Joseph3, Paweł Łajczak4, Rabbia Jabbar5, Rafael Reis de Oliveira6, Eshita Sharma7, Aishwarya Koppanatham8, Dikshit Chawla9, Yasmin Picanço Silva10, Mir Wajid Majeed11, Oguz Kagan Sahin12, Zeeshan Mansuri13, Lubna Al-Sharif14, Maryam Rizwan15, Natalia Arturo Restrepo16, Paweł Chochoł17, Thomas C. Varkey18
1Jinnah Medical and Dental College, Karachi, SINDH, Pakistan, 2Government Medical College Thiruvananthapuram, Kerala, India, 3Government Medical College Thiruvananthapuram, Kerala, 4Medical University of Silesia, Katowice, 5Fatima memorial hospital FMHCMD, Lahore, Pakistan, 6Federal University of Pará, 7David Geffen School of Medicine at UCLA, 8Andhra Medical College, Visakhapatnam, 9Government Medical College Patiala, India, 10Faculty of Medicine, University of Debrecen, Debrecen, Hungary, 11Government medical college Srinagar, 12Acibadem Mehmet Ali Aydinlar University, Istanbul, 13Gujarat Cancer Society Medical College, Ahmedabad, 14An-Nahah national University, 15Baqai Medical College, Karachi, SINDH, 16Universidad CES, Medellin, Antioquia, 17University of Warmia and Mazury in Olszty, 18University of Arizona School of Medicine Phoenix
Objective:
Our network meta-analysis (NMA) compared various antiplatelet therapies in ischemic stroke (IS) and transient ischemic attack (TIA) patients.
Background:
Antiplatelet therapy is the cornerstone of IS and TIA treatment. Studies have reported varied efficacy profiles of different antiplatelet regimens. However, the optimal antiplatelet regimen in patients with IS and TIA remains uncertain.
Design/Methods:
A comprehensive search of PubMed, Embase, and Cochrane was conducted to identify randomized controlled trials (RCTs) comparing various antiplatelet regimens in IS and TIA patients. Frequentist NMA was performed to evaluate the efficacy of these treatments in reducing early neurological deterioration (END) and mortality.
Results:
Our analysis included 36 RCTs involving 96,841 patients. Aspirin+clopidogrel (RR 0.10; 95% CI 0.04–0.25), aspirin+cilostazol (RR 0.11; 95% CI 0.04–0.29), aspirin (RR 0.16; 95% CI 0.07–0.35), cilostazol (RR 0.20; 95% CI 0.06–0.65), and tirofiban (RR 10.77; 95% CI 3.72–31.33) were all associated with a lower risk of END compared with placebo. Aspirin had a higher risk of mortality compared with aspirin + dipyridamole (RR 1.22; 95% CI 1.03–1.45). Aspirin+clopidogrel increased mortality compared with aspirin+dipyridamole (RR 1.40; 95% CI 1.11–1.77), clopidogrel (RR 1.26; 95% CI 1.03–1.54), and triflusal (RR 2.39; 95% CI 1.08–5.28). Ticagrelor had a higher mortality risk than triflusal (RR 2.44; 95% CI 1.03–5.76). In the p-score analysis, tirofiban had the highest probability of being the best treatment for reducing END, and triflusal for reducing mortality.
Conclusions:
Aspirin+clopidogrel, aspirin+cilostazol, aspirin, cilostazol, and tirofiban lowered END in patients with IS or TIA. Aspirin+clopidogrel increased mortality compared with aspirin+dipyridamole, clopidogrel, and triflusal. Tirofiban was found to be best in reducing END and triflusal for mortality.
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