A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke

Mohr, J.P. and Thompson, J.L.P. and Lazar, Ronald M. and Levin, Bruce and Sacco, R.L. and Furie, K.L. and Kistler, J.P. and Albers, G.W. and Pettigrew, L.C. and Adams, H.P. and Jackson, C.M. and Pullicino, Patrick (2001) A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. New England Journal of Medicine, 345 (20). pp. 1444-1451. ISSN 1533-4406. (The full text of this publication is not available from this repository)

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Official URL
http://dx.doi.org/10.1056/NEJMoa011258

Abstract

Background: Despite the use of antiplatelet agents, usually aspirin, in patients who have had an ischemic stroke, there is still a substantial rate of recurrence. Therefore, we investigated whether warfarin, which is effective and superior to aspirin in the prevention of cardiogenic embolism, would also prove superior in the prevention of recurrent ischemic stroke in patients with a prior noncardioembolic ischemic stroke. Methods: In a multicenter, double-blind, randomized trial, we compared the effect of warfarin (at a dose adjusted to produce an international normalized ratio of 1.4 to 2.8) and that of aspirin (325 mg per day) on the combined primary end point of recurrent ischemic stroke or death from any cause within two years. Results: The two randomized study groups were similar with respect to base-line risk factors. In the intention-to-treat analysis, no significant differences were found between the treatment groups in any of the outcomes measured. The primary end point of death or recurrent ischemic stroke was reached by 196 of 1103 patients assigned to warfarin (17.8 percent) and 176 of 1103 assigned to aspirin (16.0 percent; P=0.25; hazard ratio comparing warfarin with aspirin, 1.13; 95 percent confidence interval, 0.92 to 1.38). The rates of major hemorrhage were low (2.22 per 100 patient-years in the warfarin group and 1.49 per 100 patient-years in the aspirin group). Also, there were no significant treatment-related differences in the frequency of or time to the primary end point or major hemorrhage according to the cause of the initial stroke. Conclusions: Over a two-year period, we found no difference between aspirin and warfarin in the prevention of recurrent ischemic stroke or death or in the rate of major hemorrhage. Consequently, we regard both warfarin and aspirin as reasonable therapeutic alternatives.

Item Type: Article
Additional information: ACFC. As expected, and excellent paper. 2206 patients had all had a non-cardioembolic cerebral ischaemic event, NOT attributable to cardio-embolic event, within the previous 30 days, some major & some minor. TIAs could be included, but it seems as if those pts had to have CT or MRI evidence (Table 1). Most patients who were excluded had AF. Some had fairly severe disability (p1445 lines 6-7). Follow-up was 2 years. Very well-described and efficient trial managment. Randomised to warfarin or aspirin. Main outcome = death from any cause or recurrent ischaemic stroke - whichever occurred first. 17% had an event within the 2 year period. NO significant differences between warfarin and aspirin. Implications for practice: abstract says feel free to use either drug. End of Discussion is slightly better in implying that it seems more sensible to use the safer cheaper drug!
Uncontrolled keywords: NONVALVULAR ATRIAL-FIBRILLATION; RANDOMIZED TRIAL; SECONDARY PREVENTION; CEREBRAL INFARCTION; OPTIMAL INTENSITY; RISK FACTORS; ANTICOAGULATION; THERAPY; SUBTYPES
Subjects: R Medicine > RC Internal medicine > RC0321 Neuroscience. Biological psychiatry. Neuropsychiatry
Divisions: Faculties > Science Technology and Medical Studies > Kent Institute of Medicine and Health Sciences (KIMHS)
Depositing User: M.P. Stone
Date Deposited: 29 Oct 2008 19:15
Last Modified: 11 Jul 2014 14:24
Resource URI: http://kar.kent.ac.uk/id/eprint/12221 (The current URI for this page, for reference purposes)
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