Pomero Fulvio, Galli Eleonora, Bellesini Marta, Maroni Lorenzo, Squizzato Alessandro
Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy.
Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy; Department of Internal Medicine, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy.
Eur J Intern Med. 2022 Jun;100:46-55. doi: 10.1016/j.ejim.2022.03.017. Epub 2022 Mar 22.
Aspirin is a cornerstone of preventive treatment for stroke recurrence, but during the last few years the role of dual antiplatelet therapy (DAPT) is much more emerging.
This systematic review aimed to compare early use of P2Y12 inhibitors (clopidogrel/ticagrelor) plus aspirin to aspirin alone for acute treatment and secondary prevention in acute non-cardioembolic minor ischemic stroke or TIA.
A systematic search on MEDLINE and EMBASE was performed. Treatment effects were estimated with RRs and 95% CI. We used RevMan 5.4 for data analyses. We assessed methodological quality of selected studies according to Rob2 tools and quality of evidence with GRADE approach.
Four RCTs were included, enrolling 21,459 patients. Compared to aspirin alone, DAPT was superior in reducing stroke recurrence (RR 0.74, 95% CI 0.67-0.82, P <0.00001, absolute risk difference by 2%, NNT 50) and disabling stroke defined as mRS>2 (RR 0.84, 95% CI 0.75-0.95, P = 0.004), with no impact on all causes of mortality (RR 1.30, 95% CI 0.90-1.89, P = 0.16). An increased risk of major bleeding was emerged (RR 2.54, 95% CI 1.65-3.92, P <0.0001, absolute risk difference by 0,4%, NNH 250), in particular with ticagrelor, but there was no correlation between therapy duration and bleeding risk, as appeared from one-month (RR 3.06, 95% CI 1.64 to 5.69) and three-month (RR 2.09, 95% CI 1.18 to 3.69) follow-up analysis.
Early administration of P2Y12 inhibitors plus aspirin in patients with acute non-cardioembolic minor ischemic stroke or TIA reduced the incidence of ischemic stroke recurrence, impacting more significantly than the increased bleeding risk and influencing patients' quality of life by reducing disabling stroke.
阿司匹林是预防卒中复发治疗的基石，但在过去几年中，双联抗血小板治疗（DAPT）的作用日益凸显。
本系统评价旨在比较早期使用P2Y12抑制剂（氯吡格雷/替格瑞洛）联合阿司匹林与单用阿司匹林治疗急性非心源性轻度缺血性卒中和短暂性脑缺血发作（TIA）的疗效及二级预防效果。
对MEDLINE和EMBASE进行系统检索。采用相对危险度（RR）及95%可信区间（CI）评估治疗效果。使用RevMan 5.4进行数据分析。根据Rob2工具评估纳入研究的方法学质量，采用GRADE方法评估证据质量。
纳入4项随机对照试验，共21459例患者。与单用阿司匹林相比，DAPT在降低卒中复发风险（RR=0.74，95%CI 0.67-0.82，P<0.00001，绝对风险差异为2%，需治疗人数为50）和降低改良Rankin量表（mRS）评分>2定义的致残性卒中风险方面更具优势（RR=0.84，95%CI 0.75-0.95，P=0.004），但对全因死亡率无影响（RR=1.30，95%CI （0.90-1.89，P=0.16）。大出血风险增加（RR=2.54，95%CI 1.65-3.92，P<0.0001，绝对风险差异为0.4%，需治疗人数为250），尤其是替格瑞洛治疗时，但从1个月（RR=3.06，95%CI 1.64-5.69）和3个月（RR=2.09，95%CI 1.18-3.69）随访分析来看，治疗持续时间与出血风险之间无相关性。
急性非心源性轻度缺血性卒中和TIA患者早期给予P2Y12抑制剂联合阿司匹林可降低缺血性卒中复发率，其对降低复发率的影响显著大于出血风险增加方面，且通过降低致残性卒中影响患者生活质量。
