PMID- 12519590
OWN - NLM
STAT- MEDLINE
DCOM- 20030221
LR  - 20181221
IS  - 1469-493X (Electronic)
IS  - 1361-6137 (Linking)
IP  - 4
DP  - 2002
TI  - Anticoagulants versus antiplatelet agents for acute ischaemic stroke.
PG  - CD003242
AB  - BACKGROUND: Antiplatelet agents produce a small, but worthwhile benefit in 
      long-term functional outcome and survival, and have become standard treatment for 
      acute ischaemic stroke. Anticoagulants are often used as an alternative 
      treatment, despite evidence that they are ineffective in producing long-term 
      benefits. We wanted to review trials which have directly compared anticoagulants 
      and antiplatelet agents, to assess whether any anticoagulant regimen offers net 
      advantages over antiplatelet agents, overall or in some particular category of 
      patients (e.g. patients with atrial fibrillation). OBJECTIVES: a) To assess the 
      effectiveness of anticoagulants compared with antiplatelet agents in acute 
      ischaemic stroke b) To assess whether the addition of anticoagulants to 
      antiplatelet agents offers any net advantage over antiplatelet agents alone. 
      SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register, the 
      Cochrane Controlled Trials Register (Central/CCTR), the trials register held by 
      the Antithrombotic Therapy Trialists' Collaboration, MEDLINE (1966-2000), and 
      EMBASE (1980-2000). All searches were performed during April and May 2001. 
      SELECTION CRITERIA: Truly unconfounded, randomised-controlled trials comparing 
      anticoagulants with antiplatelet agents, or anticoagulants and antiplatelet 
      agents with antiplatelet agents alone, given within 14 days of onset of presumed 
      or confirmed ischaemic stroke. DATA COLLECTION AND ANALYSIS: Both reviewers 
      independently selected trials for inclusion in the review, assessed trial quality 
      and extracted data. MAIN RESULTS: A total of 16,558 patients from four trials 
      contributed to the analyses. The methodological quality was high in all four 
      trials. The anticoagulants tested were unfractionated heparin (UFH) and low 
      molecular-weight heparin. Aspirin was used as control in all trials. Overall, 
      there was no evidence that anticoagulants were superior to aspirin in reducing 
      'death or dependency' at long-term follow-up (odds ratio [OR] 1.07, 95% 
      confidence interval [95% CI] 0.98-1.15). Compared with aspirin, anticoagulants 
      were associated with a small but significant increase in the number of deaths at 
      the end of follow-up (OR 1.10, 95% CI 1.01-1.29), equivalent to 20 more deaths 
      (95% CI 0-30) per 1000 patients treated; a significant increased risk of 
      symptomatic intracranial haemorrhage (OR 2.35, 95% CI 1.49-3.46); and a 
      non-significant increased risk of 'any recurrent stroke' during treatment (OR 
      1.20, 95% CI 0.99-1.46). These neutral or adverse effects outweighed a small, but 
      significant effect on symptomatic deep vein thrombosis (OR 1.20, 95% CI 
      0.07-0.58), equivalent to 10 fewer (95% CI 0-30) DVTs by 14 days per 1000 
      patients treated with anticoagulants instead of aspirin. Subgroup analysis could 
      not identify any type, dose, or route of administration of anticoagulants 
      associated with net benefit, or any benefit in patients with atrial fibrillation. 
      Overall, the combination of UFH and aspirin did not appear to be associated with 
      a net advantage over aspirin alone. A subgroup analysis showed that, compared 
      with aspirin, the combination of low-dose UFH and aspirin was associated with a 
      marginally significant reduced risk of 'any recurrent stroke' (OR 0.75, 95% CI 
      0.56-1.03) and a marginally significant reduced risk of death at 14 days (OR 
      0.84, 95% CI 0.69-1.01), and with no clear adverse effect on death at end of 
      follow-up (OR 0.98, 95% CI 0.85-1.12). REVIEWER'S CONCLUSIONS: Anticoagulants 
      offered no net advantages over antiplatelet agents in acute ischaemic stroke. The 
      combination of low-dose UFH and aspirin appeared in a subgroup analysis to be 
      associated with net benefits compared with aspirin alone, and this merits further 
      research.
FAU - Berge, E
AU  - Berge E
AD  - Dept of Internal Medicine, Ulleval University Hospital, N-0407 Oslo, Norway. 
      eivind.berge@ioks.uio.no
FAU - Sandercock, P
AU  - Sandercock P
LA  - eng
PT  - Journal Article
PT  - Meta-Analysis
PT  - Review
PT  - Systematic Review
PL  - England
TA  - Cochrane Database Syst Rev
JT  - The Cochrane database of systematic reviews
JID - 100909747
RN  - 0 (Anticoagulants)
RN  - 0 (Platelet Aggregation Inhibitors)
RN  - 9005-49-6 (Heparin)
RN  - R16CO5Y76E (Aspirin)
SB  - IM
CIN - ACP J Club. 2003 Jul-Aug;139(1):5. PMID: 12841709
MH  - Anticoagulants/*therapeutic use
MH  - Aspirin/therapeutic use
MH  - Cerebral Infarction/*drug therapy
MH  - Heparin/therapeutic use
MH  - Humans
MH  - Platelet Aggregation Inhibitors/*therapeutic use
MH  - Randomized Controlled Trials as Topic
RF  - 33
EDAT- 2003/01/10 04:00
MHDA- 2003/02/22 04:00
CRDT- 2003/01/10 04:00
PHST- 2003/01/10 04:00 [pubmed]
PHST- 2003/02/22 04:00 [medline]
PHST- 2003/01/10 04:00 [entrez]
AID - 10.1002/14651858.CD003242 [doi]
PST - ppublish
SO  - Cochrane Database Syst Rev. 2002;(4):CD003242. doi: 10.1002/14651858.CD003242.