New Antiplatelet Agents Prescribed to Patients With Ischemic Heart Disease: Implications for Treatment of Stroke
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Stroke continues to be a significant public health problem worldwide. Despite a number of clinical trials testing various therapeutic agents, we are still left with a small armamentarium of options. Aspirin, clopidogrel and combination aspirin-dipyridamole remain the mainstay for prevention of recurrent ischemic stroke. Tissue plasminogen activator (tPA) or alteplase is the sole agent used in the acute phase up to 4.5 h from the onset of stroke symptoms. A greater understanding of pathophysiologic mechanisms produced an array of acute experimental treatments including intravenous magnesium and free radical scavengers. However, they did not stand up to the scrutiny of phase III randomized clinical trials. Secondary prevention of stroke benefitted more from epidemiologic studies focusing on risk factor modifications, rather than antiplatelet or other stroke specific agents. One must ask if new treatments for stroke are exhausted. Despite the frustrations of stroke neurologists, new avenues for treatment continue to be explored. One comes from our colleagues in cardiology. Development of new medications for treating ischemic heart disease, acute or chronic, may provide opportunity to cross over into stroke. Cardiovascular trials usually encompass stroke as an outcome measure. As of yet, there have not been the data to support use of these agents in stroke. Recent medications for acute and chronic phases of ischemic heart diseases include desmoteplase, tenecteplase, tirofiban, prasugrel, and ticagrelor. Though some of these medications may fail to show a benefit in stroke patients, we feel there is always potential for a breakthrough.
- Diener HC, Bogousslavsky J, Brass LM, MATCH investigators, et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet. 2004;364(9431):331–7. CrossRef
- Sacco RL, Diener HC, Yusuf S, PRoFESS Study Group, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke. N Engl J Med. 2008;359(12):1238–51. CrossRef
- Wiviott SD, Braunwald E, McCabe CH, TRITON-TIMI 38 Investigators, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001–15. CrossRef
- Koo MH, Nawarskas JJ, Frishman WH. Prasugrel: a new antiplatelet drug for the prevention and treatment of cardiovascular disease. Cardiol Rev. 2008;16(6):314–8. CrossRef
- Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361:1045–57. CrossRef
- James SK, Roe MT, for the PLATO Study Group, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial. BMJ. 2011;342:d3527. CrossRef
- James SK, Storey RF, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes and a history of stroke or transient ischemic attack. Circulation. 2012;125:2914–21. CrossRef
- AstraZeneca Press Release Thursday, 14 November 2013. This announcement is for the new trail of ticagrelor. It could theoretically provide an additional oral medication for prevention of recurrent stroke.
- Gulba DC, Praus M, Witt W. DSPA alpha – Properties of the plasminogen activators on the Vampire bat Desmodus rotundus. Fibrinolysis. 1995;9:91–6. CrossRef
- Medcalf R. Desmoteplase: discovery, insights and opportunities for ischaemic stroke. Br J Pharmacol. 2012;165(1):75–89. The results of the latest desmotelplase trials are important because it would finally add an acute treatment for stroke besides tPA. Additionally, it would extend the time window for treatment allowing more patients to potentially receive therapy. CrossRef
- Parsons M, Spratt N, Bivard A, et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med. 2012;366(12):1099–107. As with desmoteplase, this study is a step for using tenecteplase for acute ischemic stroke. Further large studies will have to be carried out to confirm the benefit. One of the controversies of tPA is that some physicians don’t see an immediate benefit. Tenecteplase showed a benefit for these patients at 24 hours. CrossRef
- McClellan KJ, Goa KL, Tirofiban. A review of its use in acute coronary syndromes. Drugs. 1998;56(6):1067–80. CrossRef
- Torgano G et al. Effect of intravenous tirofiban and aspirin in reducing short-term and long-term neurologic deficit in patients with ischemic stroke: a double-blind randomized trial. Cerebrovasc Dis. 2010;29:275–81. CrossRef
- Seibler M et al. Safety of tirofiban in acute ischemic stroke: the SaTIS trial. Stroke. 2011;42(9):2388–92. doi:10.1161/STROKEAHA.110.599662. CrossRef
- Registry Report on Kinetics of Rescue Antiplatelet Treatment to Abolish Cerebral Microemboli After Carotid Endarterectomy, Mahmud Saedon, Donald R.J. Singer, Raymand Pang, Carl Tiivas, Charles E. Hutchinson. Stroke, ISSN: 0039-2499 published online October 18, 2012. This article hints at an important subgroup of stroke patients that are still at risk for recurrent stroke. If tirofiban can prove to be beneficial in post carotid endarterectomy patients, it would take the guesswork out of prescribing the most appropriate agent.
- Lexicomp online/prasugrel. http://online.lexi.com/lco/action/home.
- Lexicomp online/ticagrelor. http://online.lexi.com/lco/action/home.
- Lexicomp online/tirofiban. http://online.lexi.com/lco/action/home.
- Lexicomp online/tenecteplase. http://online.lexi.com/lco/action/home.
- New Antiplatelet Agents Prescribed to Patients With Ischemic Heart Disease: Implications for Treatment of Stroke
Current Treatment Options in Neurology
- Online Date
- March 2014
- Print ISSN
- Online ISSN
- Springer US
- Additional Links
- Ischemic stroke
- Ischemic heart disease
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