Letter by Zhang Regarding Article, ''Early Dual Versus Mono Antiplatelet Therapy for Acute Non-Cardioembolic Ischemic Stroke or Transient Ischemic Attack: An Updated Systematic Review and Meta-Analysis'' Hong Zhang Circulation. 2014;130:e73 doi: 10.1161/CIRCULATIONAHA.113.007296 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2014 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539
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Correspondence Letter by Zhang Regarding Article, “Early Dual Versus Mono Antiplatelet Therapy for Acute Non-Cardioembolic Ischemic Stroke or Transient Ischemic Attack: An Updated Systematic Review and Meta-Analysis” To the Editor: I have read “Early Dual Versus Mono Antiplatelet Therapy for Acute Non-Cardioembolic Ischemic Stroke or Transient Ischemic Attack: An Updated Systematic Review and Meta-Analysis” by Wong and colleagues1 with great interest. In this meta-analysis, the authors included 14 randomized, controlled trials (9012 patients) comparing dual versus mono antiplatelet therapy for acute noncardioembolic ischemic stroke or transient ischemic attack (TIA) within 3 days of ictus. They found that when compared with mono antiplatelet therapy, dual therapy was associated with a reduction in stroke recurrence, and composite vascular events, but without a significant increase in the risk of major bleeding. As the authors state, they included the CHANCE (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events) trial,2 which accounted for ≈50% of participants (5170 patients) in this meta-analysis, and is a randomized, double-blind, multicenter, placebo-controlled trial designed to test efficacy and safety for clopidogrel plus aspirin against aspirin alone in the prevention of recurrent stroke in Chinese patients with acute minor stroke or TIA. We wonder whether this meta-analysis may help to modify current Chinese guidelines for stroke, or whether it is the best CHANCE for Chinese with minor ischemic stroke or TIA in the real-world clinical practice? After a TIA or stroke, patients are at a high risk of experiencing recurrent stroke, which will aggravate stroke-related neurological deficit and sometimes even lead to death. Antiplatelet therapy is a major strategy for preventing recurrent stroke in patients with stroke or TIA, as recommended by some guidelines for the control of stroke, such as those formulated by the Chinese Guideline for Stroke, the American Stroke Association, and the American Heart Association. These guidelines suggested aspirin, clopidogrel, and the combined use of aspirin and extended-release dipyridamole as acceptable alternatives for initial therapy. In Asia, dissatisfaction with poststroke recovery has led many to opt for complementary and alternative therapies. Traditional Chinese herb medicine (TCM) is 1 of the dominant forms of complementary and alternative therapies for many Asian populations, including those who have migrated to Western countries. Pharmacological studies have indicated that some TCM can be used for dilating the cardiocerebral vessels, suppressing
the aggregation of platelets, improving circulation, removing blood stasis, protecting against ischemic reperfusion injury, and enhancing the tolerance of ischemic tissue to hypoxia.3 A substantial percentage of Asian patients were likely to use TCM in combination with Western medicines. For instance, 13% of patients using anticoagulant or antiplatelet agents were also prescribed concentrated TCM concomitantly in a Taiwanese population-based study.4 The major consequences of these interactions between TCM and anticoagulant or antiplatelet were increased bleeding risks attributable to the additive anticoagulant or antiplatelet effects of the TCM.5 Currently, TCM is popular and well accepted in China for primary and secondary stroke prevention and treatment, although it has never been recommended by Chinese guidelines for the control of ischemic stroke. Thus, the possibility that TCM may increase bleeding risks should not be ignored when considering dual antiplatelet, triple antiplatelet, or even mono antiplatelet therapy for ischemic stroke or TIA.
Disclosures None. Hong Zhang, MD, PhD Department of Neurology Zhongnan Hospital of Wuhan University Wuhan, China
References 1. Wong KS, Wang Y, Leng X, Mao C, Tang J, Bath PM, Markus HS, Gorelick PB, Liu L, Lin W, Wang Y. Early dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis. Circulation. 2013;128:1656–1666. 2. Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, Wang C, Li H, Meng X, Cui L, Jia J, Dong Q, Xu A, Zeng J, Li Y, Wang Z, Xia H, Johnston SC; CHANCE Investigators. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369:11–19. 3. Wu B, Liu M, Liu H, Li W, Tan S, Zhang S, Fang Y. Meta-analysis of traditional Chinese patent medicine for ischemic stroke. Stroke. 2007;38:1973–1979. 4. Tsai HH, Lin HW, Chien CR, Li TC. Concurrent use of antiplatelets, anticoagulants, or digoxin with Chinese medications: a population-based cohort study. Eur J Clin Pharmacol. 2013;69:629–639. 5. Tsai HH, Lin HW, Lu YH, Chen YL, Mahady GB. A review of potential harmful interactions between anticoagulant/antiplatelet agents and Chinese herbal medicines. PLoS One. 2013;8:e64255.
(Circulation. 2014;130:e73.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.007296
Downloaded from http://circ.ahajournals.org/ by guest on August 26, 2014 e73
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/130/8/e73
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/
Downloaded from http://circ.ahajournals.org/ by guest on August 26, 2014
Correspondence Letter by Zhang Regarding Article, “Early Dual Versus Mono Antiplatelet Therapy for Acute Non-Cardioembolic Ischemic Stroke or Transient Ischemic Attack: An Updated Systematic Review and Meta-Analysis” To the Editor: I have read “Early Dual Versus Mono Antiplatelet Therapy for Acute Non-Cardioembolic Ischemic Stroke or Transient Ischemic Attack: An Updated Systematic Review and Meta-Analysis” by Wong and colleagues1 with great interest. In this meta-analysis, the authors included 14 randomized, controlled trials (9012 patients) comparing dual versus mono antiplatelet therapy for acute noncardioembolic ischemic stroke or transient ischemic attack (TIA) within 3 days of ictus. They found that when compared with mono antiplatelet therapy, dual therapy was associated with a reduction in stroke recurrence, and composite vascular events, but without a significant increase in the risk of major bleeding. As the authors state, they included the CHANCE (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events) trial,2 which accounted for ≈50% of participants (5170 patients) in this meta-analysis, and is a randomized, double-blind, multicenter, placebo-controlled trial designed to test efficacy and safety for clopidogrel plus aspirin against aspirin alone in the prevention of recurrent stroke in Chinese patients with acute minor stroke or TIA. We wonder whether this meta-analysis may help to modify current Chinese guidelines for stroke, or whether it is the best CHANCE for Chinese with minor ischemic stroke or TIA in the real-world clinical practice? After a TIA or stroke, patients are at a high risk of experiencing recurrent stroke, which will aggravate stroke-related neurological deficit and sometimes even lead to death. Antiplatelet therapy is a major strategy for preventing recurrent stroke in patients with stroke or TIA, as recommended by some guidelines for the control of stroke, such as those formulated by the Chinese Guideline for Stroke, the American Stroke Association, and the American Heart Association. These guidelines suggested aspirin, clopidogrel, and the combined use of aspirin and extended-release dipyridamole as acceptable alternatives for initial therapy. In Asia, dissatisfaction with poststroke recovery has led many to opt for complementary and alternative therapies. Traditional Chinese herb medicine (TCM) is 1 of the dominant forms of complementary and alternative therapies for many Asian populations, including those who have migrated to Western countries. Pharmacological studies have indicated that some TCM can be used for dilating the cardiocerebral vessels, suppressing
the aggregation of platelets, improving circulation, removing blood stasis, protecting against ischemic reperfusion injury, and enhancing the tolerance of ischemic tissue to hypoxia.3 A substantial percentage of Asian patients were likely to use TCM in combination with Western medicines. For instance, 13% of patients using anticoagulant or antiplatelet agents were also prescribed concentrated TCM concomitantly in a Taiwanese population-based study.4 The major consequences of these interactions between TCM and anticoagulant or antiplatelet were increased bleeding risks attributable to the additive anticoagulant or antiplatelet effects of the TCM.5 Currently, TCM is popular and well accepted in China for primary and secondary stroke prevention and treatment, although it has never been recommended by Chinese guidelines for the control of ischemic stroke. Thus, the possibility that TCM may increase bleeding risks should not be ignored when considering dual antiplatelet, triple antiplatelet, or even mono antiplatelet therapy for ischemic stroke or TIA.
Disclosures None. Hong Zhang, MD, PhD Department of Neurology Zhongnan Hospital of Wuhan University Wuhan, China
References 1. Wong KS, Wang Y, Leng X, Mao C, Tang J, Bath PM, Markus HS, Gorelick PB, Liu L, Lin W, Wang Y. Early dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis. Circulation. 2013;128:1656–1666. 2. Wang Y, Wang Y, Zhao X, Liu L, Wang D, Wang C, Wang C, Li H, Meng X, Cui L, Jia J, Dong Q, Xu A, Zeng J, Li Y, Wang Z, Xia H, Johnston SC; CHANCE Investigators. Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N Engl J Med. 2013;369:11–19. 3. Wu B, Liu M, Liu H, Li W, Tan S, Zhang S, Fang Y. Meta-analysis of traditional Chinese patent medicine for ischemic stroke. Stroke. 2007;38:1973–1979. 4. Tsai HH, Lin HW, Chien CR, Li TC. Concurrent use of antiplatelets, anticoagulants, or digoxin with Chinese medications: a population-based cohort study. Eur J Clin Pharmacol. 2013;69:629–639. 5. Tsai HH, Lin HW, Lu YH, Chen YL, Mahady GB. A review of potential harmful interactions between anticoagulant/antiplatelet agents and Chinese herbal medicines. PLoS One. 2013;8:e64255.
(Circulation. 2014;130:e73.) © 2014 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.007296
Downloaded from http://circ.ahajournals.org/ by guest on August 26, 2014 e73
