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 Post subject: ASPIRIN AND STROKE
PostPosted: 21 May 2016 19:28 
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Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials
Information type: Primary research
Source: The Lancet-14th May 2016.

Summary
Data from 12 trials (n=15,778) found aspirin reduced 6 week risk of recurrent ischaemic stroke (IS) vs. placebo by ~ 60% (HR 0.42, 95% CI, 0.32–0.55, p<0.0001) and disabling or fatal IS by ~70% (0.29, 0.20–0.42, p<0.0001), with greatest benefit in patients with TIA/minor stroke.

The researchers conclude their findings confirm that medical treatment substantially reduces the risk of early recurrent stroke after TIA and minor stroke and identify aspirin as the key intervention. They add that the considerable early benefit from aspirin warrants public education about self-administration after possible TIA.

According to a commentary, these results suggest that:

• The effect of aspirin in preventing early recurrent stroke and myocardial infarction after TIA and ischaemic stroke may have been underestimated.

• The effect of aspirin in preventing long-term recurrent stroke may have been overestimated.

• There is a lack of awareness of the benefits of aspirin in reducing the severity of early recurrent ischaemic stroke.

• The effect of dipyridamole in preventing long-term recurrent stroke may have been underestimated.

In terms of clinical practice, the commentary suggests that patients with suspected TIA or ischaemic stroke require urgent assessment and intervention as they have a high early risk and ongoing long-term risk of recurrent stroke and other vascular events unless the underlying cardiovascular cause and its potential consequences are appropriately treated.

In addition, aspirin is the first-line antithrombotic of choice and should be administered immediately.
The benefits in reducing the risk and severity of early recurrent stroke are greater than previously recognised. Furthermore, the potential risks associated with administering aspirin before brain imaging to exclude intracerebral haemorrhage are likely to be low, and the few RCTs of antithrombotic therapy in such patients, or patients with intracerebral haemorrhage, have not reported adverse outcomes.

However, a larger body of observational evidence suggests that antiplatelet therapy at the time of intracerebral haemorrhage might increase mortality hence caution and further research are warranted in this setting. They add that although observational studies suggest no detrimental effect of prior antiplatelet use in patients with ischaemic stroke who subsequently require thrombolysis, further research is required.

Implications of these results for public education are to raise awareness of the nature of the symptoms and signs of TIA and stroke, the high risk of early recurrent stroke even if symptoms have subsided, and the need to seek medical attention immediately.

The authors advise that for individuals with transient stroke-like symptoms that resolve within minutes to an hour, self-administration of aspirin, while awaiting medical assessment, is likely to be safe and of benefit in preventing a recurrent ischaemic event of the brain.
However, they caution that though in individuals with persistent stroke-like symptoms that could possibly be due to intracerebral haemorrhage, the overall benefits of self-administration of aspirin are also likely to offset the risks, further evaluation of such a public policy is recommended.

NB- MOHAN- The Medico legal aspects of utilising Primary research , not yet incorporated in National Guidelines is noteworthy.


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 Post subject: Re: ASPIRIN AND STROKE
PostPosted: 22 May 2016 16:11 
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Mohan,

This paper is a little confusing. Initially the authors appear to indicate that the public must be educated about the benefit of administering aspirin during early stroke. They also say that the risks of intracerebral haemorrhage is low when you administer aspirin before scanning the brain. However they conclude later that antiplatelet therapy at the time of intracerebral haemorrhage might increase mortality hence caution and further research are warranted. So what do we tell the public?


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 Post subject: Re: ASPIRIN AND STROKE
PostPosted: 25 May 2016 12:17 
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Badri,

Unfortunately the Public are confused by Newspaper articles , which dramatise with catchy headlines and at times promote incorrect understanding.

Current guidance stands as - RECOGNISE STROKE EARLY. CONTACT EMERGENCY SERVICES IMMEDIATELY . HIGH RISK OF EARLY RECURRENT STROKE EVEN IF SYMPTOMS HAVE SUBSIDED .

ASPIRIN SHOULD NOT BE GIVEN BY THE PUBLIC IN THIS SCENE.

I can't remember if i have written about Stroke, to the public?


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 Post subject: Re: ASPIRIN AND STROKE
PostPosted: 25 May 2016 12:28 
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Hi Mohan and Badri
In this context, I think it is better to recapitulate an article titled "Anticoagulants in acute stroke" by our friend late Raghuthaman and a rejoinder from me in this forum in Dec 2013. I reproduce the same below:

UA Mohammed

_______________________________________________________________________________________________________

AP Raghuthaman

Post subject: Anticoagulation in Acute Stroke

PostPosted: 30 Dec 2013 17:55


New Stroke Management Guidelines: A Quick and Easy Guide
Bret S. Stetka, MD, Helmi L. Lutsep, MD
Anticoagulation. Antiplatelet Agents Anticoagulation .

The Basics:

Urgent anticoagulation not recommended in acute ischemic stroke Urgent anticoagulation not recommended for noncerebrovascular conditions in the setting of strokeAnticoagulation with 24 hours of IV rtPA not recommended. Efficacy of thrombin inhibitors not well established in acute strokeThe Bottom Line: Trials have not yet provided indications for anticoagulation in acute stroke. Urgent anticoagulation is not recommended in acute ischemic stroke, nor is it for noncerebrovascular conditions in the setting of moderate-to-severe strokes due to an increased risk for intracerebral hemorrhage. Anticoagulation within 24 hours of IV rtPA administration is also not recommended.

New: The usefulness of argatroban and other thrombin inhibitors in acute ischemic stroke is not well established at the time of guideline publication, nor is the usefulness of anticoagulating patients with severe stenosis of an internal carotid artery ipsilateral to an ischemic stroke.Antiplatelet Agents

The Basics:
Aspirin within 24-48 hoursOther antiplatelet agents not recommended

The Bottom Line: Aspirin remains the only antiplatelet agent for which data support use in acute stroke, although trials with other agents are in progress.Oral aspirin is recommended for most patients within 24-48 hours of initial symptoms; however, it is not a suitable substitute for other acute stroke interventions, including rtPA.

Revised: Clopidogrel's usefulness is not well established, and the use of IV antiplatelet drugs that inhibit the glycoprotein IIb/IIIa receptor is not recommended. Adjunctive aspirin, or other antiplatelet therapies, within 24 hours of IV fibrinolysis are also not recommended.

New: The efficacy of glycoprotein IIb/IIIa inhibitors tirofiban and eptifibatide is not well-established.

PS This is a long article, I have just focussed on the anticoagulation aspect of treatment.

Raghuthaman




uamohammed

Post subject: Re: Anticoagulation in Acute Stroke

PostPosted: 01 Jan 2014 12:47



Hello Raghu,
This is a timely message. During the long span of our practice in general medicine we have seen a number of therapeutic adventures in the case of stroke. Finally when it comes to the result of our interventions I think we have not had much as far as patients’ outcome is concerned. When we are not able to do much, we should ensure that what we do should not cause any harm to the patients. Some years ago I burnt my fingers when I was treating a CT proved brain infarction. After a few days of starting aspirin I saw his condition was deteriorating. A repeat CT scan brain showed haemorrhage over the previous infarct lesion.
In the same way the enthusiastic and radical treatment of hypertension also fraught with danger. The development of hypertension in a previously normotensive person is a healthy natural reaction. In normal persons the blood circulations in each hemisphere of the brain is strictly confined to the same side, without getting mixed with the other side. But when ischemia develops on one side the blood flow is maintained from across the midline. This is accomplished by increasing the systemic blood pressure. With our overenthusiasm to treat this high blood pressure we actually create a steal phenomenon on the affected side further jeopardising the ischemic state. So judicial use of anti-hypertensive therapy is what is required.
Another point to be born in mind while managing the stroke is the care we must take in treating diabetes mellitus. In the case of stroke the hypoglycaemia is more dangerous than hyperglycaemia. Even during our student days one of our teachers used to tell us that it was better to err on hyperglycaemic side. The younger generation nowadays bent of strict blood sugar control. While in the hospital it is usual to give multiple injections of insulin. Even though patients are averse to frequent blood checking, the next dose of insulin should be given only after checking the blood sugar, at least by glucometer. Most dangerous hypoglycaemia develops usually in the wee hours of mornings when the patient is in sleep and by-standers are also dozing and the hospital staff are in a lax state.

UA Mohammed


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 Post subject: Re: ASPIRIN AND STROKE
PostPosted: 28 May 2016 22:03 
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Friends, all your messages are well worth spreading. What I gather from all this discussion is that aspirin is the only drug worth considering when you come across a stroke patient. However Heamorrhagic Stroke must be ruled out by relevant tests before starting or continuing any anticoagulant therapy.

Mohan, The format of our "Forum" has been changed, any one (public) can now read all the articles posted by registered members, although they cannot comment on it. But to make it easier for them to understand, a summary of what has been discussed here can be presented on the Home page "your health". May be you can create one.


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 Post subject: Re: ASPIRIN AND STROKE
PostPosted: 29 May 2016 13:29 
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Dear Badri,

That is a welcome step. I think more and more general public will come to this site and know what is going on in the medical field world over. They will know that this site is meant for the expansion of medical knowledge among the doctors and the general public.

UA Mohammed


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 Post subject: Re: ASPIRIN AND STROKE
PostPosted: 30 May 2016 22:18 
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Mohammed,

Thank you for your support. You can tell your patients to look at a specific topic if they come to you with a problem that we have discussed.

Badri.


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