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New Knowledge, Drug Strategies, and Treatments Are Improving Post-Stroke Outcomes: Presented at ACP-ASIM

By Bonnie Darves

NEW ORLEANS, LA -- April 26, 2004 -- New thinking about management of post-stroke patients and those who experience transient ischemic attacks (TIAs), coupled with the emergence of promising new drugs, may soon lead to markedly better outcomes.

In his presentation here at the American College of Physicians - American Society of Internal Medicine Annual Session, Robert Hart, MD, professor of neurology, University of Texas, San Antonio, Texas, stressed 3 key points: that warfarin is no better than acetylsalicylic acid (ASA) after noncardioembolic stroke -- and might be associated with worse outcomes; that aspirin is a useful and effective therapy for secondary stroke prevention; and that minutes count when using tissue plasminogen activator (tPA) after stroke.

Dr. Hart also urged physicians to remember that lowering blood pressure after stroke yields such potentially large benefits that more focus should be placed on this aspect of post-stroke treatment. Dr. Hart also gave high marks to the new oral anticoagulant drug ximelagatran.

"Ximelagatran is the new kid on the block and the first new anticoagulant in 50 years -- and the good news is that one dose fits all, except in patients with renal [problems]," Dr. Hart said. Ximelagatran -- a direct thrombin inhibitor expected to receive approval from the Food and Drug Administration (FDA) in the coming weeks -- requires no anticoagulation monitoring. In addition, the dosing of 36 mg BID appears to need no adjustment, making it potentially superior to anticoagulants whose monitoring can become problematic in certain patients.

"It's a better than average anticoagulant, based on the studies, and the incidence of major bleeding is the same [as with warfarin]," Dr. Hart said in support of ximelagatran, adding that the FDA ruling and its particular recommendations regarding liver monitoring, is awaited anxiously.

In discussing new approaches for treatment of acute stroke, he reported an emerging shift in thinking regarding administration of tissue plasminogen activator (tPA). While the guidelines call for delivering the drug within 3 hours of stroke for maximum benefit, new studies are showing promising results at both ends of the administration-time spectrum. If tPA is given within 90 minutes of acute stroke onset, "chances of a good outcome are 3-fold higher," Dr. Hart said, and there is also increasing evidence that administration as late as 4.5 hours after onset may produce some benefit.

In acute stroke, experimental approaches such as use of neuroprotective agents and hypothermia are not showing outcomes benefit, but early ASA may produce some benefit. In addition, IV heparin should be avoided at all costs, based on the results of several trials and recently revised guidelines. "The trials and the guidelines are consistent on this, but half of U.S. neurologists still routinely give [the drug]," Dr. Hart said.

He urged attendees to be aware of the near-term risks for stroke in patients who experience TIAs. While it was once thought that TIAs were a medium-term (1 year or more) precursor for stroke, there is emerging evidence that the short-term risk of stroke following TIA is greater than that. "New studies show that the short-term risk of stroke after TIA is more dangerous than most of us thought. Now we know that the risk is higher in the first few weeks -- TIAs are not benign and we now treat [TIA and stroke] patients much the same way," he said.


[Presentation Title: Management Issues in TIA and Stroke.]

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