Stroke guidelines receive support

The National Stroke Association announced that it supports new stroke treatment and prevention guidelines released by the American College of Chest Physicians. The guidelines appeared in the November 1998 issue of Chest.

The guidelines recommend treatment of acute ischemic stroke within three hours of symptom onset with a recombinant form of tissue plasminogen activator. Aspirin, ticlopidine, clopidogrel or a combination of aspirin and extended-release dipyridamole were recommended as acceptable options of recurrent stroke treatment.

Treatment with low doses of aspirin (see Pharmaceutical Representative, December 1998, p. 9) was recommended as an initial choice for stroke patients for the prevention of recurrent stroke. The combination of aspirin and extended-release dipyridamole may be more effective than clopidogrel with similarly favorable adverse side effects, the guidelines' authors noted.

For patients who are intolerant of aspirin therapy, the authors recommended antiplatelet therapy. They recommended a daily dose of 75 mg of clopidogrel over a twice-daily dose of 250 mg of ticlopidine, citing lower incidence of side effects.

Foundation for treatment

The stroke guidelines were developed based on data from several studies, including the National Institute of Neurological Disorders and Stroke recombinant tissue plasminogen activator Stroke Study Group trials.

In the trials, researchers found that patients treated with tissue plasminogen activator were at least 30% more likely to have minimal or no disability at three months compared with placebo-treated patients. The mortality rate at three months was 17% in the tissue plasminogen activator group and 21% in the placebo group.

In the European Stroke Prevention Study, researchers found that combining extended-release dipyridamole and aspirin reduced risk of stroke recurrence by 37% versus placebo, and reduced the risk of secondary stroke by 23% over that of aspirin alone.

Also, in the Ticlopidine Aspirin Stroke Study, ticlopidine was approximately 20% more effective than aspirin alone in reducing stroke, and 10% better than aspirin in reducing composite outcome of stroke, myocardial infarction or vascular death. However, researchers noted, ticlopidine is associated with 1% incidence of severe neutropenia and a 5% to 10% incidence of dermatologic reactions and diarrhea.

Finally, the Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events study showed that clopidogrel is slightly more effective than aspirin in reducing the combined risk of stroke, myocardial infarction or vascular death in patients with atherosclerotic vascular disease. PR