Secondary prevention in minor ischemic stroke with antiplatelet treatment. Systematic review and meta-analysis of comparative studies with aspirin under non-inferiority criteria. / Prevención secundaria en el ictus isquémico menor con el tratamiento antiplaquetario. Revisión sistemática y metanálisis de estudios comparativos con aspirina bajo criterios de no inferioridad.
Resumen
Abstract.
Minor ischemic stroke is the most frequent presentation of cerebral vascular disease and treatment with antiplatelet drugs can be used for the prevention of its recurrence. This systematic review and meta-analysis was aimed to assess non-inferiority criteria about the effect in the comparison of different antiplatelet schemes using aspirin as active control. Twelve randomized studies with a total of 52204 patients were chosen. All met the inclusion criteria with minor recurrent ischemic stroke as end point and any extracranial bleeding as safety event. The results showed a significant risk reduction of 22% [RR (95% CI) = 0.78 (0.72-0.84), p<0.0001, NNT: 67] in the recurrence of ischemic events with any antiplatelet drug (combined or not with aspirin) versus aspirin alone and there were no differences in the bleeding risk [RR (95% CI) = 1.02 (0.74- 1.41), p= 0.899, NNH: 500]. Dual antiplatelet therapy (DAPT) and cilostazol were more effective compared with aspirin alone (22% and 32% risk reduction respectively) but only cilostazol showed a higher reduction (52%) of bleeding events. In conclusion, although in some instances equivalence was demonstrated, a clinical superiority in the risk reduction for recurrent ischemic stroke of any antiplatelet treatment versus aspirin alone was observed. With the sole exception of the cilostazol trials there was an increase of the bleeding risk when the antiplatelet drugs treatments were compared with aspirin alone.
Resumen.
El accidente cerebrovascular (ictus) isquémico menor es la presentación más frecuente de enfermedad vascular cerebral y se puede utilizar el tratamiento con fármacos antiplaquetarios para la prevención de su recurrencia. Esta revisión sistemática y metanálisis tuvo como objetivo evaluar los criterios de no inferioridad sobre el efecto en la comparación de diferentes esquemas antiplaquetarios que usan aspirina como control activo. Se eligieron doce estudios aleatorios con un total de 52.204 pacientes. Todos cumplieron los criterios de inclusión para ictus isquémico recurrente menor como desenlace primario y hemorragia extracraneal como evento de seguridad. Los resultados mostraron una reducción significativa del riesgo del 22% [RR (IC 95%) = 0,78 (0,72-0,84), p <0,0001, NNT: 67] en la recurrencia de eventos isquémicos con cualquier fármaco antiplaquetario (combinado o no con aspirina) versus aspirina sola y no hubo diferencias en el riesgo de hemorragia [RR (IC 95%) = 1.02 (0.74-1.41), p = 0.899, NNH: 500]. La terapia antiplaquetaria dual (DAPT) y el cilostazol fueron más efectivos en comparación con la aspirina sola (22% y 32% de reducción de riesgo respectivamente) pero solo el cilostazol mostró una mayor reducción (52%) de los eventos hemorrágicos. En conclusión, aunque en algunos casos se demostró la equivalencia, se observó una superioridad clínica en la reducción del riesgo de accidente cerebrovascular isquémico recurrente de cualquier tratamiento antiplaquetario versus aspirina sola. Con la única excepción de los ensayos con cilostazol, hubo un aumento del riesgo de hemorragia cuando los tratamientos con fármacos antiplaquetarios se compararon con la aspirina sola.
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