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Anti-thrombosis therapy questioned

23-May-08

European Stroke Conference: Doubts over gold standard therapy, benefit of early mobility and birth weight.

The gold standard in anti-thrombosis therapy is no more effective than second-line treatment, according to the largest study into secondary stroke prevention to date.

Current NICE guidelines, due to be reviewed shortly, suggest giving stroke patients dipyrimadole plus aspirin, or, if this proves unsuitable, clopidogrel.

But findings from the international Preventative Regimen for Effectively Avoiding Secondary Strokes (PRoFESS) trial, showed no significant differences between the two regimens regarding stroke prevention or incidence of MI or vascular death.

The study involved 20,332 patients with ischaemic stroke who were randomly assigned to each of the regimens for an average of two and half years.

Nine per cent of those given the dipyrimadole (200mg) plus aspirin (25mg) combination twice daily had a stroke, similar to the 8.8 per cent incident rate in the clopidogrel arm.

Analysis showed that 7.7 per cent in the combination group and 7.9 per cent in the clopidogrel group had ischaemic stroke.

Analysis of secondary out-comes in the head-to-head study showed rates of MI and vascular death were also the same at 13.1 per cent, delegates were told at the European Stroke Conference in Nice, France, last week.

Although the benefit to risk ratio was said to be similar be-tween the two groups in the study, major haemorrhagic events and intracranial bleeds were noted in 4.1 per cent of those randomised to dipyrimadole plus aspirin, compared with 3.6 per cent of those given clopidogrel.

Dropouts due to headache were also more common in the dipyrimadole plus aspirin arm, than with clopidogrel.

Dr Mark Welton, a Staffordshire GP with a special interest in cerebrovascular disease, said he was 'surprised by the results'.

'NICE recommend aspirin and dipyridamole as the most effective antiplatelet combination and it has been assumed that this combination is better than just clopidogrel,' he said.

'In fact we only really use clopidogrel where patients don't tolerate aspirin, even with a proton pump inhibitor.'

However, he added: 'I don't think it will majorly change present practice - it's just a bit disappointing that aspirin and dipyridamole isn't better than clopidogrel which is what we previously thought.'

rachel.liddle@haymarket.com

European Stroke Conference online

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