Comparative efficacy and safety of multiple antiplatelet therapies for secondary prevention of ischemic stroke or transient ischemic attack: A network meta-analysis

• Published in: Journal of the neurological sciences 2019-04, Vol.399, p.199-206
• Main Authors: Xiang, Rong-wu, Han, Ruo-bing, Yang, Jing-yu, Zhao, Ming-yi, Zhao, Qing-chun, Chen, Hui-sheng, Zhao, Fang-qing, Sun, Zhong-yi, Zhao, Tong, Song, Ting-yan
• Format: Article
• Language: English
• Subjects: Antiplatelet; Network meta-analysis; Secondary prevention; Stroke; Transient ischemic attack; Visual
• ISSN: 0022-510X; 1878-5883
• DOI: 10.1016/j.jns.2019.02.037

Antiplatelet therapies for secondary prevention of ischemic stroke or transient ischemic attack (TIA) is a highly active research topic with five critical drugs obtained by visual analysis. We aimed to compare and rank multiple antiplatelet therapies using a network meta-analysis. Relevant medical databases were searched. Eligible randomized controlled trials (RCTs) which examined any comparisons involving mono- or dual antiplatelet therapies, based on aspirin, clopidogrel, dipyridamole, ticlopidine, cilostazol and placebo for patients with noncardioembolic ischemic stroke or TIA, were included. 14 outcomes were assessed. Primary outcomes were stroke recurrence, composite events (stroke recurrence, myocardial infarction and vascular death), and intracranial hemorrhage. PROSPERO registered number CRD42017069728. 45 RCTs with 173,131 patients were included in network meta-analysis, involving eight antiplatelet therapies. Cilostazol and clopidogrel were statistically more efficacious than aspirin (odds ratio (OR) = 0.64, 95% confidence interval (CI) = 0.47–0.88; OR = 0.77, 95%CI = 0.62–0.95) and dipyridamole (OR = 0.64, 95%CI = 0.44–0.93; OR = 0.76, 95%CI = 0.58–0.99) in reducing stroke recurrence, and showed significant benefits in reducing composite events compared with aspirin (OR = 0.63, 95%CI = 0.45–0.89; OR = 0.90, 95%CI = 0.83–0.97). No significant difference was found between cilostazol and clopidogrel in intracranial hemorrhage. Weighted regression suggested cilostazol was hierarchically the optimum treatment in consideration of both efficacy and safety, followed by clopidogrel. Cilostazol and clopidogrel are probably promising options for secondary prevention of ischemic stroke or TIA. Both of them reduce stroke recurrence similarly compared with aspirin or dipyridamole, and reduce composite events compared with aspirin. Further studies are needed to confirm this finding. •Cilostazol and clopidogrel are promising options for secondary prevention of ischemic stroke or TIA.•Cilostazol and clopidogrel reduce stroke recurrence compared with aspirin or dipyridamole.•Cilostazol and clopidogrel reduce composite events compared with aspirin.•Dipyridamole performs well in safety but poorly in efficacy.•Clopidogrel plus aspirin and dipyridamole plus aspirin perform well in efficacy but poorly in safety.