| To fib or not to fib | Blood is thicker than water | FAT CAT | Do. Or Do Not. There is No Try. |
|---|---|---|---|
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2009- Active A- plavix + aspirin vs. aspirin alone
2006- Active W- plavix + aspirin vs. coumadin ACTIVE- A- RCT comparing Asa/Plavix to asa in patients with atrial fibrillation (2009) not suitable for warfarin-- decreased risk of stroke, increased risk of bleeding ACTIVE-W- RCT comparing Asa/Plavix to Warfarin in patients with atrial fibrillation ( 2006) -- Warfarin was superior to asa/plavix for stroke prevention
What is the primary difference between ACTIVE-A and ACTIVE-W?
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Noninferiority to warfarin with respect to stroke, decreased overall risk of death/ICH, increased risk of GI Bleed.
What were the results of the ROCKET-AF trial?
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Atrial Fibrillation
SPARCL- High dose Atorvastatin(80mg) compared to placebo in patients with hx of stroke/TIA of atherosclerotic origin ( 1-6 months) with NO CAD, lowered the incidence of strokes ( 13.1% vs. 11.2%), and was associated with increased risk of recurrent ICH in pts with recent ICH.
What group of patients were excluded from the SPARCL trial?
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90 days
SAMMPRIS-(2011) - Carotid stenting vs. aggressive medical mangement in symptomatic intracranial stenosis (70-99%), aggressive medical therapy was shown to be superior ( rate of stroke /death was 14% in intervention vs. 5.8% in medical group at first 30 days- consistent at 1 year)
What duration of aggressive medical treatment was tested in SAMMPRIS?
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Embrace- 30 day monitor
CRYSTAL AF- implanted monitors - f/u at 6, 12 months CRYSTAL - AF- (2014)RCT comparing insertable cardiac monitoring vs. conventional follow up within 90 days of cryptogenic stroke or TIA-- superior in detecting A fib at 6 (8.9% vs. 1.4%)months and 9 months (12.4% vs. 2%) EMBRACE (2014) - RCT comparing 30 day noninvasive monitoring to 24 hour monitoring for cryptogenic stroke/TIA in last 6 months - more patients being on anticoagulation at 90 days ( 16.1% vs. 3.7%), and 18.6% on anticoagulation vs 11% at 90 days.
What is the difference in duration of monitoring between CRYSTAL-AF and EMBRACE?
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Age >80, 2- Cr >1.5, Weight < 60kg (higher risk of bleeding and thrombembolic events)
ARISTOTLE ( 2011) - RCT comparing Apixaban vs. Warfarin in patients with atrial fibrillation- Apixaban 5mg BID is superior to warfarin for prevention of stroke, and showed decreased ICH, major bleeding and death compared to warfarin.
What criteria are used to determine reduced dose of Apixaban from ARISTOTLE data?
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70-99%
NASCET- (1991) - Carotid Endarterctomy vs. best medical therapy in symptomatic Internal Carotid stenosis ( 70-99%) have lowered risk of stroke/death (9% vs. 26% at 2 years).
What range of stenosis had significant benefit in the NASCET trial?
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6 hours
MR CLEAN- Intrarterial therapy with 2nd gen vascular retrieval devices/IV t-PA vs. IV- t-PA in large proximal anterior circulation strokes in the first 6 hours improved functional independence at 90 days, no increase in ICH/mortality. (median modified rankin scale 3 vs. 4- OR 1.67)
What was the window of time evaluated for intra-arterial therapy in the MR CLEAN trial?
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Watchman Device
Unblinded RCT comparing watchman device 9( percutaneous left atrial appendage closure for stroke prophylaxis )- superior in reducing death/hemorrhagic stroke, noninferior to Warfarin for prevention
What device was studied in the PROTECT-AF trial?
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Secondary Prevention after TIA/CVA
CHANCE- Plavix/Aspirin vs. Aspirin in TIA/CVA ( within 24 hours of onset) - decreased risk of stroke (8.2% vs. 11.7% at 90 days) without increasing risk of moderate- severe hemorrhage ( 0.3% vs. 0.3%) MATCH- (2004) - Asa/Plavix vs. Plavix for secondary prevention among all pts with recent TIA/CVA -- found no significant benefit and increased risk of hemorrhage ( 18 month follow up, 53% of CVA were lacunar).
What is the population targeted in the MATCH and CHANCE trials?
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COSS- EC- IC Bypass surgery plus medical therapy vs. medical therapy in patients with recently symptomatic atherosclerotic occlusion did not reduce the risk of recurrent stroke at 2 years
Is there a benefit to EC-IC bypass with symptomatic atherosclerotic occlusion?
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No significant difference in mortality between CEA and CAS in BOTH asymptomatic and symptomatic extracranial carotid stenosis- increased peri- op risk of stroke with CAS in elderly patients
What were the results of the 2010 CREST trial?
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Danish Cohort Study
ICH HR-- Asa/warfarin - 1.44, triple therapy- 1.36 Plavix/Warfarin - 1.32 Risk of Bleeding with Single, Dual, or Triple therapy- 2010- ( warfarin, aspirin, plavix) in patients with Atrial Fibrillation- combo therapy increases bleeding complications without lowering the incidence of ischemic stroke.
What type of study was the risk of bleeding with single, dual, or triple therapy in patients with atrial fibrillation?
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6.4%
NINDS- (1995) IV t-PA in the first 3 hours of ischemic stroke compared to placebo was associated with an improved 3 month global outcome, as well as increased rate of symptomatic ICH at 36 hours.
What was the rate of ICH at 36 hours in the 1995 NINDS trial?
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CRP> 2
JUPITER- ( 2010)- Rosuvastatin in primary prevention of stroke among patients with CRP>2 and LDL < 130 ( exclude pts inflammatory disorders) showed reduction in CVA rates ( Relative risk reduction of 48% in median 1.9 years) - only seen when baseline CRP>5 or achieved CRP<2.
Rosuvastatin was shown to have a significant benefit in primary prevention of stroke in this trial that included patients of LDL<130 and CRP>2
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CLOSE- PFO (with associated atrial septal aneurysm OR large intratrial shunt) + antiplatelet alone vs. anticoagulation alone vs. antiplaletet alone
REDUCE- PFO (moderate-large shunt) +antiplatelet vs. antiplatelet therapy alone.
What are the CLOSE and REDUCE trials studying?
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DEFUSE 3- Core <70, NIHSS>6
DAWN: Core <51 cc, NIHSS (for 51 cc)- >20
Differences in inclusion criteria of DAWN and DEFUSE-3: Core size and NIHSS
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