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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Antiplatelet therapy, most notably aspirin, has been well documented to reduce risks of subsequent cardiovascular disease (CVD) in secondary prevention, acute myocardial infarction (MI), acute occlusive stroke, as well as in primary prevention. In secondary prevention, the most recent Antithrombotic Trialists' Collaboration reviewed 194 published randomized trials of antiplatelet therapy, mostly aspirin, involving more than 212 000 patients (ie, 135 000 using antiplatelet therapy or control and 77 000 using different antiplatelet regimens). In a very wide range of patients who have survived a prior occlusive vascular event-including MI, transient ischemic attacks, occlusive stroke, unstable and stable angina, percutaneous coronary interventions, and coronary artery bypass graft-aspirin prevents about 25% of serious vascular events. Among patients suffering acute Ml or acute occlusive stroke, aspirin begun promptly and continued long-term reduces risks of subsequent MI, stroke, and vascular death. In acute coronary syndromes, clopidogrel added to aspirin further reduces the risk of important vascular events, but not mortality, and causes more side effects, especially bleeding. For patients undergoing percutaneous coronary interventions, the addition of a short-term infusion of a glycoprotein IIb/IIIa receptor antagonist to aspirin prevents additional vascular events during the early in-hospital period but also increases the risk of major bleeding. Ongoing research is investigating other combinations of different antiplatelet drugs. In all these high-risk patients, there is a small excess of major bleeding among those assigned at random to aspirin, which is far outweighed by the magnitude of benefits on CVD. During an acute MI, after a loading dose of 160 mg to 325 mg aspirin, daily doses ranging from 75 to 150 mg daily are as effective as higher doses. For long-term treatment, the effects of doses < 75 mg daily are less certain. Although side effects are dose-related, especially in doses > 325 mg daily, no antiplatelet regimen is more effective than aspirin for long-term use. In primary prevention, 5 randomized trials have been published involving more than 60 000 apparently healthy men and women. Persons randomized to receive aspirin in these trials had significant reductions in risk of a first MI (32%) and important vascular events (15%). Since the numbers of strokes and vascular deaths were insufficient to distinguish between the benefits found in secondary prevention and no effect, use of aspirin in primary prevention should be weighed in light of the cardiovascular risk profile, the side effects of the drug, and its clear benefit in reducing risk of a first MI. Aspirin should be an adjunct, not an alternative, to managing other cardiovascular risk factors. Recently, the US Preventive Services Task Force and the American Heart Association recommended aspirin use for all men and women whose 10-year risks are > 6% and > or = 10%, respectively. In all these patient categories, including secondary prevention, acute MI and acute occlusive stroke, as well as primary prevention, increased and appropriate use of aspirin will prevent large numbers of premature deaths and MIs.
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PMID:Update on aspirin in the treatment and prevention of cardiovascular disease. 1251 36

Platelets play a central role in both the short- and long-term manifestations of atherothrombosis. In acute coronary syndrome (ACS), there is a steep rise in cardiovascular events early, followed by an incremental rise in cardiovascular events over the long term. This long-term event rate is related to persistent platelet activation and thrombin generation. There is therefore a need to optimize both short- and long-term oral antiplatelet and antithrombotic strategies. The benefits of aspirin therapy, when administered early and continued over the long term, were demonstrated in several early randomized trials. The Antithrombotic Trialists' Collaboration found a 46% reduction in vascular events with antiplatelet therapy (mostly aspirin). However, despite treatment with aspirin and proven therapies, recurrent events remain high. The adenosine diphosphate receptor antagonists, ticlopidine and clopidogrel, inhibit the early steps of platelet activation, degranulation, and release of prothrombotic and inflammatory mediators, while also preventing activation of the glycoprotein IIb/IIIa receptor. The Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial demonstrated the benefits of aspirin plus clopidogrel in reducing major cardiovascular events (cardiovascular death, myocardial infarction [MI], and stroke reduced by 20%, p = 0.00009) in a broad range of patients with ACS when administered early and continued over the long term. The benefits emerge very rapidly after a 300 mg loading dose. For the large number of patients undergoing percutaneous coronary intervention in the CURE trial, there was a substantial risk reduction with clopidogrel pretreatment followed by long-term therapy (p < 0.002). This benefit was present, regardless of whether intervention was performed early or late. The significant benefits of aspirin and clopidogrel persist for the combined efficacy-safety end point of cardiovascular death, MI, stroke, or life-threatening bleeding when clopidogrel is started early, combined with aspirin and other standard therapies, and continued for up to one year.
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PMID:Short- and long-term oral antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention. 1264 45

Atherosclerosis, with its thromboembolic complications (including sudden cardiac death, myocardial infarction, and other ischemic organ damage such as stroke and ischemic renovascular disease), represents by far the major cause of death, morbidity, and disability for industrialized countries, and is rapidly spreading worldwide. Atherosclerosis is also a paradigm for complex, multifactorial disorders that affect humans in an age-dependent fashion. Atherosclerosis has usually been studied in a descriptive framework of biological and clinical data gathered over more than a century. As such, it is a chronic inflammatory process that selectively affects arterial vessels, and is, at least in part, genetically predetermined. Despite spectacular progress in the cardiovascular discipline, with the development of therapeutic strategies that have substantially improved the outcome of affected patients, several key questions remain unanswered: Why is aging such a powerful risk for coronary artery disease? What is the triggering mechanism for atherosclerotic inflammation? Also, in the context of this and accompanying reviews, do we modify coronary inflammation with glycoprotein IIb/IIIa blockers? Recent progress in our understanding of the underlying process of atherosclerosis has provided us with the opportunity to refine the answers to some of these questions.
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PMID:Inflammation, platelets, and glycoprotein IIb/IIIa inhibitors. 1266 59

Antiplatelet drugs protect against myocardial infarction, stroke, cardiovascular death and other serious vascular events in patients with a history of previous vascular events or known risk factors for cardiovascular disease. Aspirin reduces the risk of serious vascular events in patients at high risk of such an event by about a quarter and is recommended as the first-line antiplatelet drug. Clopidogrel reduces the risk of serious vascular events among high-risk patients by about 10% compared with aspirin. It is as safe as aspirin, but much more expensive. It is an appropriate alternative to aspirin for long-term secondary prevention in patients who cannot tolerate aspirin, have experienced a recurrent vascular event while taking aspirin, or are at very high risk of a vascular event (>/= 20% per year). Addition of clopidogrel to aspirin reduces the risk of serious vascular events among patients with non-ST-segment elevation acute coronary syndromes by 20%, and patients undergoing percutaneous coronary intervention by 30%, compared with aspirin alone. Addition of a glycoprotein IIb/IIIa receptor antagonist to aspirin reduces the risk of vascular events among patients with non-ST-segment elevation acute coronary syndromes by 10% and among patients undergoing percutaneous coronary intervention by 30%, compared with aspirin alone; it appears to provide incremental benefit in patients also treated with clopidogrel. Addition of dipyridamole to aspirin seems to be more effective than aspirin alone for preventing recurrent stroke, but its overall effect in preventing serious vascular events in patients with ischaemic stroke and transient ischaemic attack has not been determined.
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PMID:Antiplatelet drugs. 1276 6

Antiphospholipid syndrome (APS) is an uncommon prothrombotic disorder that has been increasingly recognized in recent years. The diagnosis of APS must be associated with venous or arterial thrombosis or both. Patients with APS usually present with recurrent deep vein thrombosis, pulmonary thromboembolism, thromboembolic stroke, or myocardial infarction. Here, we report a case of a 61-year-old female who presented with a 3-month history of increasingly frequent retrosternal chest tightness. After treadmill test and thallium-201 myocardial perfusion scan, she was admitted and underwent elective coronary angiography but developed acute thrombosis after direct intracoronary stenting. She was successfully rescued with repeat percutaneous transluminal coronary angioplasty and prolonged heparin and glycoprotein IIb/IIIa antagonist use. Laboratory data showed prolongation of partial thromboplastin time and positive anti-cardiolipin antibody. These findings satisfied the criteria for APS; the patient was diagnosed with primary APS because she had neither typical symptoms nor signs of systemic lupus erythematosus or other immunologic disorders. Thereafter, long-term oral anticoagulant appeared to be effective. To our knowledge, this is the first report of acute stent thrombosis in a patient with primary APS.
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PMID:Acute thrombosis after elective direct intracoronary stenting in primary antiphospholipid syndrome: a case report. 1279 47

The cardiovascular continuum describes the way from risk factors to atherosclerosis, acute cardiovascular events (unstable angina and myocardial infarction), and development of terminal heart failure and its complications. Following this way, advances are reported in the therapy of acute coronary syndrome, heart failure, ventricular and supraventricular tachyarrhythmias, and stroke in patients with patent foramen ovale. The following issues are reported in detail: (1) significance of statins and statin withdrawal, glycoprotein IIb/IIIa receptor blocker, acute coronary interventions, aspirin and clopidogrel in unstable coronary syndromes, (2) pathogenesis of acute pulmonary edema associated with hypertension, (3) cardiac regeneration capability after transplantation and myocardial infarction, (4) beta-blocker therapy, efficacy of additional angiotensin receptor blocker therapy and multisite biventricular pacing in symptomatic (advanced) heart failure, (5) prognosis after ablation of the atrioventricular node in patients with atrial fibrillation, (6) primary prevention with an implantable defibrillator and resumption of driving after implantation, and (7) therapeutic options after cryptogenic stroke and patent foramen ovale.
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PMID:[Update cardiology 2001/2002-part II. From unstable coronary syndrome to terminal heart failure]. 1281 17

Outcomes in elderly patients with acute coronary syndromes are worse than in younger patients, and disappointingly, some therapies, such as thrombolysis for ST elevation myocardial infarction, appear to have less relative benefit than in younger patients. However, in unstable angina and non-ST elevation myocardial infarction, the elderly appear to derive greater relative and absolute benefit from the newer more potent antithrombotic therapies. With the glycoprotein IIb/IIIa inhibitors, an equivalent relative benefit has been observed, which translated into a greater absolute benefit in older vs. younger patients. Similarly, when comparing clopidogrel plus aspirin to aspirin alone, there was a consistent 20% reduction in cardiovascular death, myocardial infarction, or stroke in both elderly and younger patients. An emerging area of focus, however, is that of the appropriate dose in the elderly. Because the elderly on average have worse renal function, many drugs will not be cleared as well, and thus higher plasma levels will exist, which can translate into higher bleeding complications. Future studies are evaluating downward dose-adjustment of new therapies in the elderly as a means of improving the efficacy/safety profile. Thus, in unstable angina and non-ST elevation myocardial infarction, elderly patients are at higher risk and appear to derive particular benefit from more aggressive antithrombotic and interventional therapies.
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PMID:Elderly patients with acute coronary syndromes: higher risk and greater benefit from antiplatelet therapy and/or interventional therapies. 1288 7

Four intravenous glycoprotein IIb/IIIa receptor inhibitors (GPIs) (abciximab, eptifibatide, tirofiban and lamifiban) have been tested extensively over the last decade for their efficacy and safety in patients with acute coronary syndromes (ACS). GPIs are well-established adjunct agents for patients undergoing percutaneous coronary intervention, and considerable effort has gone into evaluating these agents in patients who are not scheduled to undergo coronary revascularisation. In the current article, six major randomised clinical trials conducted in the latter patient population are reviewed. Based on a recent meta-analysis of these trials, GPIs reduced the incidence of death or myocardial infarction in patients not scheduled for early revascularisation, with the greatest reduction observed in patients at high risk of thrombotic complications. Major bleeding complications were more frequent in those receiving GPIs, however, the incidences of intracranial haemorrhage and stroke were similar in both treatment groups. Despite these risks, the benefits of GPI therapy in addition to conventional treatment, such as aspirin and heparin, should be considered for these high-risk patients.
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PMID:Risk-benefit analysis of platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. 1290 24

This paper provides an overview on the actual state of acute therapy in patients with ischemic stroke. The discussion focusses on intravenous and intraarterial thrombolysis, antithrombotic therapy, and the treatment of medical and neurological complications, and therapy recommendations are presented. Finally ongoing studies, particularly those concerning thrombolysis with glycoprotein IIb/IIIa receptor blockers and ultrasound-assisted thrombolysis, are presented.
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PMID:[Treatment of acute stroke -- an overview]. 1457 19

Of 1,369 consecutive patients who underwent stent-assisted coronary angioplasty and who were treated with glycoprotein IIb/IIIa inhibitors during these procedures, 17.5% were >or=75 years of age. Compared with patients <75 years old, those >or=75 years of age had similar procedural and in-hospital outcomes but significantly higher rates of hemorrhagic stroke (0.08% vs 1.2%, p <0.001).
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PMID:Comparison of effect of glycoprotein IIb/IIIa inhibitors during percutaneous coronary interventions on risk of hemorrhagic stroke in patients >or=75 years of age versus those <75 years of age. 1458 60


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