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Silimon N, Drop B, Clénin L, Nedeltchev K, Kahles T, Tarnutzer AA, Katan M, Bonati L, Salmen S, Albert S, Salerno A, Carrera E, Berger C, Peters N, Medlin F, Cereda C, Bolognese M, Kägi G, Renaud S, Niederhauser J, Bonvin C, Schärer M, Mono ML, Luft A, Rodic-Tatic B, Fischer U, Jung S, Arnold M, Meinel T, Seiffge D. Ischaemic stroke despite antiplatelet therapy: Causes and outcomes. Eur Stroke J 2023; 8:692-702. [PMID: 37622482 PMCID: PMC10472957 DOI: 10.1177/23969873231174942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 04/24/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Ischaemic stroke may occur despite antiplatelet therapy (APT). We aimed to investigate frequency, potential causes and outcomes in patients with ischaemic stroke despite APT. METHODS In this cohort study, we enrolled patients with imaging-confirmed ischaemic stroke from the Swiss Stroke Registry (01/2014-07/2022). We determined the frequency of prior APT, assessed stroke aetiology (modified TOAST classification) and determined the association of prior APT with unfavourable functional outcome (modified Rankin Scale score 3-6) and recurrent ischaemic stroke at 3 months using regression models. RESULTS Among 53,352 patients, 27,484 (51.5%) had no prior antithrombotic treatment, 17,760 (33.3%) were on APT, 7039 (13.2%) on anticoagulation and 1069 (2.0%) were on APT + anticoagulation. In patients with a history of ischaemic stroke/TIA (n = 11,948; 22.4%), 2401 (20.1%) had no prior antithrombotic therapy, 6594 (55.2%) were on APT, 2489 (20.8%) on anticoagulation and 464 (3.9%) on APT + anticoagulation. Amongst patients with ischaemic stroke despite APT, aetiology was large artery atherosclerosis in 19.8% (n = 3416), cardiac embolism in 23.6% (n = 4059), small vessel disease in 11.7% (n = 2011), other causes in 7.4% (n = 1267), more than one cause in 6.3% (n = 1078) and unknown cause in 31.3% (n = 5388). Prior APT was not independently associated with unfavourable outcome (aOR = 1.06; 95% CI: 0.98-1.14; p = 0.135) or death (aOR = 1.10; 95% CI: 0.99-1.21; p = 0.059) at 3-months but with increased odds of recurrent stroke (6.0% vs 4.3%; aOR 1.26; 95% CI: 1.11-1.44; p < 0.001). CONCLUSIONS One-third of ischaemic strokes occurred despite APT and 20% of patients with a history of ischaemic stroke had no antithrombotic therapy when having stroke recurrence. Aetiology of breakthrough strokes despite APT is heterogeneous and these patients are at increased risk of recurrent stroke.
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Affiliation(s)
- Norbert Silimon
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Boudewijn Drop
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Leander Clénin
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal Hospital of Aarau, Aarau, Switzerland
| | - Timo Kahles
- Department of Neurology, Cantonal Hospital of Aarau, Aarau, Switzerland
| | | | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Reha Rheinfelden, Rheinfelden, Switzerland
| | | | - Sylvan Albert
- Stroke Unit, Cantonal Hospital Graubünden, Chur, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Nils Peters
- Stroke Center, Klinik Hirslanden, Zürich, Switzerland
| | | | - Carlo Cereda
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | | | - Georg Kägi
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology, Cantonal Hospital of St. Gallen, St. Gallen, Switzerland
| | - Susanne Renaud
- Neurology and Stroke Unit, Neuchâtel Hospital Network, Neuchâtel, Switzerland
| | | | | | | | | | - Andreas Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | | | - Urs Fischer
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Simon Jung
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
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Pan X, Liang P, Teng L, Ren Y, Peng J, Liu W, Yang Y. Study on molecular mechanisms of nattokinase in pharmacological action based on label-free liquid chromatography-tandem mass spectrometry. Food Sci Nutr 2019; 7:3185-3193. [PMID: 31660132 PMCID: PMC6804763 DOI: 10.1002/fsn3.1157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/11/2019] [Accepted: 06/16/2019] [Indexed: 01/10/2023] Open
Abstract
Cardiovascular diseases (CVDs) are the leading causes of premature death and disability in people around the world. Therefore, the prevention and treatment of CVDs has become an important subject. In this study, we verified the thrombolytic activities of a nattokinase-like protease named NK-01 in vivo. Label-free liquid chromatography-tandem mass spectrometry (LC-MS/MS) technique was used in our study. NK-01 could inhibit the activity of coagulation factors though the up-regulation of proteinase C inhibitors and protein S. NK-01 also could inhibit the angiotensinogen conversion to AngII and promote the degradation of kininogen to reduce the blood pressure. In addition, NK-01 could increase the content of paraoxonase 1, which could prevent atherosclerosis. In our study, we found that NK-01 cloud effect some key proteins which participant in CVDs associated metabolic processes such as coagulation system, blood pressure, and atherosclerosis. Taken together, the underlying molecular mechanisms for the biological beneficial of NK-01 were investigated. Our proteomic study will provide further theoretical basis for application of NK in prevention or adjuvant treatment in biomedicine areas.
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Affiliation(s)
- Xia Pan
- Key Laboratory of Marine Genetics and Breeding, College of Marine Life SciencesOcean University of ChinaQingdaoChina
| | - Pengyu Liang
- Key Laboratory of Marine Genetics and Breeding, College of Marine Life SciencesOcean University of ChinaQingdaoChina
| | - Luyao Teng
- Key Laboratory of Marine Genetics and Breeding, College of Marine Life SciencesOcean University of ChinaQingdaoChina
| | - Yuhao Ren
- Key Laboratory of Marine Genetics and Breeding, College of Marine Life SciencesOcean University of ChinaQingdaoChina
| | - Jixian Peng
- Shandong Ruiying Pioneer Pharmaceutical Co., LtdHezeChina
| | - Weizhi Liu
- Key Laboratory of Marine Genetics and Breeding, College of Marine Life SciencesOcean University of ChinaQingdaoChina
- Laboratory for Marine Biology and BiotechnologyQingdao National Laboratory for Marine Science and TechnologyQingdaoChina
| | - Yan Yang
- Key Laboratory of Marine Genetics and Breeding, College of Marine Life SciencesOcean University of ChinaQingdaoChina
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Abstract
Aspirin is the most widely prescribed drug for the primary and secondary prevention of cardiovascular and cerebrovascular diseases. However, a large number of patients continue to experience thromboembolic events despite aspirin therapy, a phenomenon referred to as aspirin resistance or treatment failure. Aspirin resistance is often observed along with a high incidence of unstable plaque, cardiovascular events and cerebrovascular accident. Studies have shown that aspirin reduces the production of TXA2, but not totally inhibits the activation of platelets. In this review, we analyze current and past research on aspirin resistance, presenting important summaries of results regarding the potential contributive roles of single nucleotide polymorphisms, inflammation, metabolic syndrome and miRNAs. The aim of this article is to provide a brief review on aspirin resistance and platelet function, which will provide important insights into the research of aspirin resistance.
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Affiliation(s)
- Gang Du
- Department of Cardiology, The First Affiliated Hospital of Jinan University, Guangzhou, China; Center for Health Informatics and Bioinformatics, New York University School of Medicine, New York, NY, USA
| | - Qiang Lin
- Department of Rehabilitation, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jinhua Wang
- Center for Health Informatics and Bioinformatics, New York University School of Medicine, New York, NY, USA; Laura and Isaac Perlmutter Cancer Center, New York University School of Medicine, New York, NY, USA; Departments of Pediatrics, New York University School of Medicine, New York, NY 10016, USA.
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Rajkumar CA, Floyd CN, Ferro A. Antiplatelet therapy as a modulator of stroke aetiology: a meta-analysis. Br J Clin Pharmacol 2015; 80:331-41. [PMID: 25784356 DOI: 10.1111/bcp.12630] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 03/09/2015] [Accepted: 03/13/2015] [Indexed: 11/28/2022] Open
Abstract
AIMS Antiplatelet therapy reduces the incidence of ischaemic stroke. Platelet-mediated thrombosis contributes variably to the major subtypes of stroke as defined by the TOAST criteria: large artery atherosclerosis (LAA), cardioembolic (CE) and small vessel occlusion (SVO). The effect of antiplatelet therapy on the incidence of each subtype is unknown and is the subject of this meta-analysis. METHODS Electronic databases were searched for articles comparing the effect of antiplatelet therapy on the incidence of stroke according to aetiological subtype. Studies containing subjects prescribed anticoagulant therapy or solely investigating subjects with atrial fibrillation were excluded. Pooled odds ratios (ORs) were calculated using a fixed effects model. RESULTS Nine studies were included (n = 5739). In patients who had an ischaemic stroke, pre-event antiplatelet therapy was associated with significantly decreased incidence of LAA (OR 0.88, 95% CI 0.79, 0.99; P = 0.026), increased incidence of CE (OR 1.23, 95% CI 1.08, 1.41; P = 0.002) and no effect on SVO (OR 0.99, 95% CI 0.88, 1.11; P = 0.806). Concordant non-significant trends were observed in primary prevention populations (n = 751): LAA (OR 0.81, 95% CI 0.57, 1.15; P = 0.240), CE (OR 1.29, 95% CI 0.89, 1.87; P = 0.179) and SVO (OR 0.99, 95% CI 0.73, 1.36; P = 0.970). Subgroup analysis of aspirin monotherapy (n = 3786) demonstrated a significant reduction in LAA (OR 0.87, 95% CI 0.76, 1.00; P = 0.046), but non-significant effects on the incidence of CE (OR 1.17, 95% CI 0.99, 1.39; P = 0.068) and SVO (OR 1.04, 95% CI 0.91, 1.20; P = 0.570). Probability of publication bias was low (P > 0.05). CONCLUSIONS Antiplatelet therapy preferentially reduces the incidence of LAA stroke compared with CE and SVO subtypes.
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Affiliation(s)
- Christopher A Rajkumar
- Department of Clinical Pharmacology, Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Christopher N Floyd
- Department of Clinical Pharmacology, Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
| | - Albert Ferro
- Department of Clinical Pharmacology, Cardiovascular Division, British Heart Foundation Centre of Research Excellence, King's College London, London, United Kingdom
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Abstract
BACKGROUND Most strokes are due to blockage of an artery in the brain by a blood clot. Prompt treatment with thrombolytic drugs can restore blood flow before major brain damage has occurred and improve recovery after stroke in some people. Thrombolytic drugs, however, can also cause serious bleeding in the brain, which can be fatal. One drug, recombinant tissue plasminogen activator (rt-PA), is licensed for use in selected patients within 4.5 hours of stroke in Europe and within three hours in the USA. There is an upper age limit of 80 years in some countries, and a limitation to mainly non-severe stroke in others. Forty per cent more data are available since this review was last updated in 2009. OBJECTIVES To determine whether, and in what circumstances, thrombolytic therapy might be an effective and safe treatment for acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (last searched November 2013), MEDLINE (1966 to November 2013) and EMBASE (1980 to November 2013). We also handsearched conference proceedings and journals, searched reference lists and contacted pharmaceutical companies and trialists. SELECTION CRITERIA Randomised trials of any thrombolytic agent compared with control in people with definite ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors applied the inclusion criteria, extracted data and assessed trial quality. We verified the extracted data with investigators of all major trials, obtaining additional unpublished data if available. MAIN RESULTS We included 27 trials, involving 10,187 participants, testing urokinase, streptokinase, rt-PA, recombinant pro-urokinase or desmoteplase. Four trials used intra-arterial administration, while the rest used the intravenous route. Most data come from trials that started treatment up to six hours after stroke. About 44% of the trials (about 70% of the participants) were testing intravenous rt-PA. In earlier studies very few of the participants (0.5%) were aged over 80 years; in this update, 16% of participants are over 80 years of age due to the inclusion of IST-3 (53% of participants in this trial were aged over 80 years). Trials published more recently utilised computerised randomisation, so there are less likely to be baseline imbalances than in previous versions of the review. More than 50% of trials fulfilled criteria for high-grade concealment; there were few losses to follow-up for the main outcomes.Thrombolytic therapy, mostly administered up to six hours after ischaemic stroke, significantly reduced the proportion of participants who were dead or dependent (modified Rankin 3 to 6) at three to six months after stroke (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.78 to 0.93). Thrombolytic therapy increased the risk of symptomatic intracranial haemorrhage (OR 3.75, 95% CI 3.11 to 4.51), early death (OR 1.69, 95% CI 1.44 to 1.98; 13 trials, 7458 participants) and death by three to six months after stroke (OR 1.18, 95% CI 1.06 to 1.30). Early death after thrombolysis was mostly attributable to intracranial haemorrhage. Treatment within three hours of stroke was more effective in reducing death or dependency (OR 0.66, 95% CI 0.56 to 0.79) without any increase in death (OR 0.99, 95% CI 0.82 to 1.21; 11 trials, 2187 participants). There was heterogeneity between the trials. Contemporaneous antithrombotic drugs increased the risk of death. Trials testing rt-PA showed a significant reduction in death or dependency with treatment up to six hours (OR 0.84, 95% CI 0.77 to 0.93, P = 0.0006; 8 trials, 6729 participants) with significant heterogeneity; treatment within three hours was more beneficial (OR 0.65, 95% CI 0.54 to 0.80, P < 0.0001; 6 trials, 1779 participants) without heterogeneity. Participants aged over 80 years benefited equally to those aged under 80 years, particularly if treated within three hours of stroke. AUTHORS' CONCLUSIONS Thrombolytic therapy given up to six hours after stroke reduces the proportion of dead or dependent people. Those treated within the first three hours derive substantially more benefit than with later treatment. This overall benefit was apparent despite an increase in symptomatic intracranial haemorrhage, deaths at seven to 10 days, and deaths at final follow-up (except for trials testing rt-PA, which had no effect on death at final follow-up). Further trials are needed to identify the latest time window, whether people with mild stroke benefit from thrombolysis, to find ways of reducing symptomatic intracranial haemorrhage and deaths, and to identify the environment in which thrombolysis may best be given in routine practice.
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Affiliation(s)
- Joanna M Wardlaw
- University of EdinburghCentre for Clinical Brain SciencesThe Chancellor's Building49 Little France CrescentEdinburghUKEH16 4SB
| | - Veronica Murray
- Danderyd HospitalDepartment of Clinical Sciences, Karolinska InstitutetStockholmSwedenSE‐182 88
| | - Eivind Berge
- Oslo University HospitalDepartment of Internal MedicineOsloNorwayNO‐0407
| | - Gregory J del Zoppo
- University of WashingtonDepartment of Medicine (Division of Hematology), Department of Neurology325 Ninth AvenueBox 359756SeattleWashingtonUSA98104
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