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Haemorrhagic stroke during anti-platelet therapy

Published online by Cambridge University Press:  01 February 2008

M. Cattaneo
M. Cattaneo*
Affiliation:
Unità di Ematologia e Trombosi, Dipartimento di Medicina, Chirurgia e Odontoiatria, Ospedale San PaoloUniversità di Milano, Milano, Italy
*
Correspondence to: Marco Cattaneo, Unit of Hematology and Thrombosis, Ospedale San Paolo, DMCO, University of Milano, Via di Rudinì, 8. 20142 Milano, Italy. E-mail: marco.cattaneo@unimi.it; Tel/Fax: +39 02 89121827
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Summary

Drugs that inhibit platelet function are widely used to decrease the risk of occlusive arterial events in patients with atherosclerosis. There are three families of anti-platelet agents with proven clinical efficacy: (1) cyclo-oxygenase inhibitors, such as aspirin; (2) adenosine diphosphate receptor antagonists, such as the thienopyridine compounds ticlopidine and clopidogrel; and (3) glycoprotein IIb/IIIa antagonists. All these drugs are used during coronary interventions and in the medical management of acute coronary syndromes, while only aspirin and thienopyridine compounds are used in the long-term prevention of cardiovascular and cerebrovascular events in patients at risk. Despite the good risk-to-benefit ratio of anti-platelet agents, the risk of severe bleeding complications, including cerebral haemorrhage, is slightly increased, albeit to a much lesser extent than that associated with the use of other antithrombotic drugs, such as anticoagulants or thromobolytic agents. In addition, it must be noted that the increased incidence of haemorrhagic stroke is usually outweighed by a significant decrease in the incidence of ischaemic strokes. The combination of aspirin and vitamin K antagonists may be associated with the heightened risk of cerebral haemorrhage, compared to treatment with either drug alone.

Keywords

CEREBRAL HAEMORRHAGEPLATELETSANTI-PLATELET AGENTSFIBRINOLYTIC AGENTS
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 25 , Issue S42 , February 2008 , pp. 12 - 15
Copyright
Copyright © European Society of Anaesthesiology 2008

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References

1.Cattaneo, M. Aspirin and clopidogrel. Efficacy, safety and the issue of drug resistance. Arterioscler Thromb Vasc Biol 2002; 24: 1980–1987.CrossRefGoogle Scholar
2.Agah, R, Plow, EF, Topol, EJ. AIIbβ3 (GPIIb-IIIa) antagonists. In: Michelson, AD, ed. Platelets, 2nd edn. Burlington, MA: Academic Press, 2006: 1145–1163.Google Scholar
3.ISIS-2 (Second International Study on Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. Lancet 1988; 2: 349–360.Google Scholar
4.Chinese Acute Stroke Trial Collaborative Group. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. Lancet 1997; 349: 1641–1649.CrossRefGoogle Scholar
5.International Stroke Trial Collaborative Group. The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous hepatin, both, or neither among 19,435 patients with acute ischaemic stroke. Lancet 1997; 349: 1569–1581.CrossRefGoogle Scholar
6.UK-TIA Study Group. United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: interim analysis. BMJ 1988; 296: 316–320.CrossRefGoogle Scholar
7.Peto, R, Gray, R, Collins, R et al. . Randomised trial of prophylactic daily aspirin in British male doctors. BMJ 1988; 296: 313–316.CrossRefGoogle ScholarPubMed
8.Steering Committee of the Physicians’ Health Study Group. Final report on the aspirin component of the ongoing Physicians’ Health Study. N Engl J Med 1989; 321: 129–135.CrossRefGoogle Scholar
9.Ridker, PM, Cook, NR, Lee, IM et al. . A randomised trial of low-dose aspirin in the primary prevention of cardiovascular disease in women. N Engl J Med 2005; 352: 1293–1304.CrossRefGoogle ScholarPubMed
10.The SALT Collaborative Group. Swedish Aspirin low-dose trial (SALT) of 75 mg aspirin as secondary prophylaxis after cerebrovascular ischaemic events. Lancet 1991; 338: 1345–1349.CrossRefGoogle Scholar
11.He, J, Whelton, PK, Vu, B, Klag, MJ. Aspirin and risk of hemorrhagic stroke: a meta-analysis of randomized controlled trials. JAMA 1998; 280: 1930–1935.CrossRefGoogle ScholarPubMed
12.Antiplatelet Trialists’ Collaboration. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high-risk patients. BMJ 2002; 324: 71–86.CrossRefGoogle Scholar
13.Hart, RG, Benavente, O, Pearce, LA. Increased risk of intracranial hemorrhage when aspirin is combined with warfarin: a meta-analysis and hypothesis. Cerebrovasc Dis 1999; 9: 215–217.CrossRefGoogle ScholarPubMed
14.Shireman, TI, Howard, PA, Kresowik, TF, Ellerbeck, EF. Combined anticoagulant-antiplatelet use and major bleeding events in elderly atrial fibrillation patients. Stroke 2004; 35: 2362–2367.CrossRefGoogle ScholarPubMed
15.Fang, MC, Chang, Y, Hylek, EM et al. . Advanced age, anticoagulation intensity, and risk for intracranial hemorrhage among patients taking warfarin for atrial fibrillation. Ann Intern Med 2004; 141: 745–752.CrossRefGoogle ScholarPubMed
16.Berwaerts, J, Webster, J. Analysis of risk factors involved in oral-anticoagulant-related intracranial haemorrhages. Q J Med 2000; 93: 513–521.CrossRefGoogle ScholarPubMed
17.Lechat, P, Lardoux, H, Mallet, A et al. . Anticoagulant (fluindione) aspirin combination in patients with high-risk atrial fibrillation. A randomized trial (Fluindione, Fibrillation Auriculaire, Aspirin et Contraste Spontane; FFAACS). Cerebrovasc Dis 2001; 12: 245–252.CrossRefGoogle ScholarPubMed
18.Stroke Prevention in Atrial Fibrillation Investigators. Adjusted-dose warfarin versus low-intensity, fixed dose warfarin plus aspirin for high-risk patients with atrial fibrillation: the Stroke Prevention in Atrial Fibrillation III randomised clinical trial. Lancet 1996; 348: 633–638.CrossRefGoogle Scholar
19.Perez-Gomez, F, Alegria, E, Berjon, J et al. . Comparative effects of antiplatelet, anticoagulant, or combined therapy in patients with valvular and nonvalvular atrial fibrillation: a randomised multicenter study. J Am Coll Cardiol 2004; 44: 1557–1566.CrossRefGoogle ScholarPubMed
20.CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348: 1329–1339.CrossRefGoogle Scholar
21.Gorelick, PB, Richardson, D, Kelly, M et al. . Aspirin and ticlopidine for prevention of recurrent stroke in black patients: a randomized trial. JAMA 2003; 289: 2947–2957.CrossRefGoogle ScholarPubMed
22.Diener, HC, Bogousslavsky, J, Brass, LM et al. . Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004; 364: 331–337.CrossRefGoogle ScholarPubMed
23.Bhatt, DL, Fox, KA, Hacke, W et al. . Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med 2006; 354: 1706–1717.CrossRefGoogle ScholarPubMed
24.Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without St-segment elevation. N Engl J Med 2001; 345: 1329–1339.Google Scholar
25.EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994; 330: 956–961.CrossRefGoogle Scholar
26.Aguirre, FV, Topol, EJ, Ferguson, JJ et al. . Bleeding complications with the chimeric antibody to platelet glycoprotein IIb/IIIa integrin in patients undergoing percutaneous coronary intervention. EPIC Investigators. Circulation 1995; 91: 2882–2890.CrossRefGoogle ScholarPubMed
27.CAPTURE Study Investigators. Randomised placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina: the CAPTURE Study. Lancet 1997; 349: 1429–1435.CrossRefGoogle Scholar
28.The EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. N Engl J Med 1997; 336: 1689–1696.CrossRefGoogle Scholar
29.Lincoff, AM, Califf, RM, Moliterno, DJ et al. . Complementary clinical benefits of coronary-artery stenting and blockade of platelet glycoprotein IIb/IIIa receptors. N Engl J Med 1999; 341: 319–327.CrossRefGoogle ScholarPubMed
30.Akkerhuis, KM, Deckers, JW, Lincoff, AM et al. . Risk of stroke associated with abciximab among patients undergoing percutaneous coronary intervention. JAMA 2001; 286: 78–82.CrossRefGoogle ScholarPubMed
31.Westerhout, CM, Boersma, E. Risk-benefit analysis of platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes. Expert Opin Drug Saf 2003; 2: 49–58.CrossRefGoogle ScholarPubMed
32.Cattaneo, M. P2Y12 receptor antagonists: a rapidly expanding group of antiplatelet agents. Eur Heart J 2006; 27: 1010–1012.CrossRefGoogle ScholarPubMed