Antithrombotic therapy for patients with acute cerebral infarction/TIA, see what the latest guidelines say?

*For medical professionals to read and refer to the 2022 update of the Korean Stroke Clinical Practice Guidelines, the key points are at a glance! Compared with the European and American populations, the Chinese, Japanese and Korean populations are more similar in terms of diet, living habits and the incidence of some special diseases.
Analysis of the treatment guidelines of the Korean and Japanese Stroke Associations for patients with acute ischemic stroke can also be used for stroke in China.
The clinical treatment has considerable reference significance
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Recently, the Korean Stroke Association has updated the antithrombotic treatment plan for patients with acute ischemic stroke or transient ischemic attack.
The author specially translates the key parts of it for peer reference, as follows: Introduction to the main international guidelines and the Korean Stroke Society (KSS) previous Clinical Practice Guidelines (CPG) recommended aspirin monotherapy as acute antithrombotic therapy
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However, aspirin has little effect on AIS; therefore, large clinical trials have investigated more effective antithrombotic regimens
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In 2013, the Clopidogrel in Patients at High Risk of Acute Nondisabling Cerebrovascular Events (CHANCE) trial demonstrated for the first time that dual antiplatelet therapy (DAPT) of clopidogrel plus aspirin was more effective than aspirin monotherapy in mild AIS or high-risk transient patients in China.
Great benefit for patients with cerebral ischemic attack (TIA)
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The Platelet-Directed Inhibition of New TIA and Minor Ischemic Stroke (POINT) trial was later replicated in a wider racial population and reinforced the results of the CHANCE trial
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Currently, DAPT with clopidogrel plus aspirin is recognized and recommended as the standard of care for patients with mild AIS or high-risk TIA
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Triple antiplatelet therapy and ticagrelor monotherapy have been studied in clinical trials, but these regimens are no more effective than standard antiplatelet therapy
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Long-term oral non-vitamin K antagonist anticoagulants (NOACs) or long-term oral anticoagulants with warfarin are strongly recommended for secondary stroke prevention in patients with atrial fibrillation (AF) and ischemic stroke or TIA
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However, there are no clinical trial data on the optimal timing of initiating oral anticoagulants in the acute phase, when the risk of recurrent ischemic stroke and hemorrhagic transformation (HT) is high
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However, oral anticoagulation in patients with AIS and atrial fibrillation is widely used worldwide
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 Recently, some guidelines have updated their recommendations for oral anticoagulants for AIS and atrial fibrillation based on observational studies and expert consensus
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To reflect the accumulated evidence, the Korea Health Authority CPG Committee decided to revise the Korea CPG for stroke to provide updated recommendations for antithrombotic therapy in patients with AIS or TIA
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 The purpose of this guideline update is to help patients make informed decisions and improve the quality of care for antithrombotic therapy
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Multiple treatment decisions must be made by responsible healthcare providers, patients and/or their caregivers
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 Previous guidelines The previous 2009 Korean Antiplatelet Therapy CPG and 2014 Korean Anticoagulant Therapy CPG provided the following recommendations for patients with AIS
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2 Acute stroke management 2.
3 Acute treatment 2.
3.
4 Antiplatelet drugs 1.
For AIS patients who exclude bleeding, oral aspirin (loading dose 160 to 300 mg) should be started within 24 to 48 hours after onset [Level of Evidence (LOE): Ia, Recommended rating (GOR): A]
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2.
Aspirin is not a substitute for acute interventions, including intravenous thrombolysis (LOE: Ia, GOR: A)
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3.
Aspirin should not be taken within 24 hours of thrombolytic therapy (LOE: Ia, GOR: A)
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4.
Intravenous administration of glycoprotein IIb/IIIa receptor antagonists, including abciximab (LOE: Ib, GOR: A), is not recommended in patients with AIS.
2.
3.
5 Anticoagulants 1.
There is no scientific evidence that in the absence of Heparin is useful within 48 hours after hemorrhagic cerebral infarction
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Compared with aspirin, it may increase the risk of bleeding (LOE
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Ia, GOR: A)
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2.
It is not recommended to use low molecular weight heparin or heparin-like drugs as an early treatment for cerebral infarction (LOE: Ia, GOR: A)
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3.
Anticoagulants (LOE:IIa, GOR:B) are not recommended within 24 hours after the injection of recombinant tissue plasminogen activator
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The level of evidence involved in this article is as follows: Key points of the 2022 Korean guideline update Differences between the new and old Korean guidelines Comparison of the similarities and differences between the Chinese and Korean guidelines From the perspective of the Korean updated guideline, it is also affected by relevant clinical research in China.
It is relatively large, especially the CHANCE experiment led by Professor Wang Yongjun, which can be said to have rewritten the clinical guidelines of many countries
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From a general perspective, for the East Asian population, the incidence of intracranial vascular stenosis caused by atherosclerosis is higher than that in European and American countries, so the East Asian population has a greater demand for antithrombotic therapy
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Currently in the traditional Chinese textbook (Neurology, 8th edition, published by People's Health Publishing House, published in August 2018), for patients with acute cerebral infarction of large artery atherosclerosis, within 24 hours of onset, and NIHSS score ≤3 Aspirin combined with clopidogrel dual-antibody therapy is not recommended for patients with 100,000 patients, but the 2022 version of the current Korean guidelines believes that aspirin combined with clopidogrel dual-antibody therapy may be more beneficial for such patients
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Some scholars at home and abroad believe that for patients with acute cerebral infarction who need antithrombotic therapy, it should be taken orally according to the kilogram of body weight.
The recommended aspirin dose in South Korea is 160-300 mg, while the current mainstream scholars in China believe that it is 150 mg.
-325mg
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In terms of anticoagulation, in fact, Chinese and Korean scholars are basically highly consistent, and anticoagulation should be started as soon as possible when the risk of bleeding is small
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In the use of glycoprotein IIb/IIIa receptor antagonists, Chinese scholars have a wider range of indications, and Korean scholars recommend their use in endovascular interventional therapy.
Patients, tirofiban also has a good therapeutic effect
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In conclusion, China and South Korea have the same basic concept of antithrombotic therapy for patients with acute ischemic stroke or transient ischemic attack, but there are differences in some details
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 First publication of the text: Neurology Channel of the Medical Community Author: Liu Peihui Review Expert: Li Tuming, Deputy Chief Physician Responsible Editor: Mr.
Lu Li We make any promises and guarantees about the accuracy and completeness of the cited materials (if any), and do not assume any responsibility for the outdated contents, possible inaccuracies or incompleteness of the cited materials
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Relevant parties are requested to check separately when adopting or using it as a basis for decision-making
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