Reticular Meta-analysis And Modified TOAST Classification Study Of Antiplatelet Drug Therapy For Ischemic Stroke

Objective: The efficacy and risk of hemorrhage of aspirin,clopidogrel,cilostazol,dipyridamole and ticarelor alone or in combination in the long-term prevention of ischemic stroke or transient ischemic attack were evaluated by network meta-analysis.Methods :We searched PubMed,Medline,Embase,TheCochrane Library and other databases by computer according to the retrieval strategy to comprehensively collect the randomized controlled studies published before September 30,2018 on antiplatelet therapy for ischemic stroke or transient ischemic attack.After the studies that met the inclusion criteria were screened out by two researchers independently,the risk assessment tool of bias provided by the Cochrane manual was used to assess the risk of the included studies.Effective data were extracted and statistical analysis was conducted using Stata14.0 and GeMTC software.Results: A total of 26 trials including 88,755 patients were included in this study.Consistency model was used for mesh meta analysis of the four outcome indicators.There were 25 related studies on stroke recurrence events.The results of traditional meta-analysis indicated that,compared with aspirin,cilostazol(OR= 0.65 95%CI=0.50-0.85),aspirinplus clopidogrel(OR= 0.75 95%CI=0.64-0.88)and ticarelor(OR=0.8495%CI=0.76-0.94)could reduce the recurrence rate of stroke,and the difference was statistically significant.The results of network meta analysis indicated that,aspirin(OR=0.74 95%CI=0.59-0.93),aspirin combined with dipyridemole(OR=0.66 95%CI=0.53-0.83),clopidogrel(OR=0.65 95%CI=0.50-0.85),ticarelor(OR=0.62 95%CI=0.47-0.83),aspirin plus clopidogrel(OR=0.61 95%CI=0.47-0.81),and cilostazol(OR=0.51 95%CI=0.36-0.75)was significantly more effective than placebo in preventing stroke recurrence,in which cilostazole was the most effective.There are 23 study reports the compound vascular events occur,the tradit-ional meta analysis results,compared with aspirin,cilostazol plus aspirin(OR = 0.46,95% CI = 0.22-0.97),cilostazol(OR = 0.69,95% CI= 0.56-0.85),aspirin and clopidogrel(OR = 0.78,95% CI = 0.71-0.87),ticarelor(OR=0.86,95% CI = 0.78-0.95)of compound vascular events probability is low.The difference was statistically significant.The results of network meta-analysis showed that compared with placebo,the probability of complex vascular events was aspirin(OR=0.72 95%CI=0.60-0.87),aspirin plus dipyridamole(OR=0.66 95%CI=0.56-0.79),clopidogrel(OR=0.65 95%CI=0.53-0.79),ticarelor(OR=0.62 95%CI=0.50-0.77),aspirin plus clopidogrel(OR=0.61 95%CI=0.49-0.74),cilostazol(OR=0.54 95%CI=0.43-0.71),and aspirin plus cilostazol(OR=0.3295%CI=0.16-0.74)in descending order,with statistically significant differences.There were 18 related studies on bleeding events,and the results of network meta-analysis showed that aspirin(OR=2.37 95%CI=1.10-5.05)and aspirin plus clopidogrel(OR=3.90 95%CI=1.74-8.90)had a higher risk of bleeding than placebo.Compared with aspirin and clopidogrel,the bleeding risk of aspirin(OR=0.61 95%CI=0.43-0.83),ticarelor(OR=0.4895%CI =0.25-0.88),aspirin plus dipyridamole(OR=0.45 95%CI=0.28-0.73),clopidogrel(OR=0.37 95%CI =0.22-0.61),and cilostazol(OR=0.18 95%CI =0.08-0.33)decreased successively,with statistically significant differences.As for the death events,there were 16 related studies.The results of traditional meta-analysis and network meta-analysis indicated that there was no statistically significant difference between the two groups.The rank probability diagram shows that the group with cilostazol plus aspirin may have the lowest incidence of death,followed by the group with cilostazol,and the group with the highest incidence,possibly the placebo group.Conclusions : In the long-term anti-platelet secondary prophylaxis of ischemic stroke and transient ischemic attack,cilostazol is significantly superior to other treatment options in terms of comprehensive efficacy and security,and may reduce the risk of death.However,the currentlyincluded studies on cilostazol,are all from Asia,and more studies on the secondary prevention of cilostazol in non-asian patients are needed in the future.The combined effect of aspirin and clopidogrel was superior to other regimens except for cilostazol,but the risk of bleeding was significantly higher than that of other groups.Compared with aspirin,the combined efficacy of clopidogrel,ticarelor and aspirin combined with dipyridamole was better and the risk of bleeding was lower,but the number of studies included in some schemes was small and more studies were needed to prove.Objective:To analysis the proportion of ischemic stroke(IS)patients in the Northeast of Sichuan Province according to the modified TOAST classification and the relationship between the risk factors among the IS subtypes.Methods:The clinical data was collected from 732 consective ischemic stroke impatients in the Neurology Department of Nanchong Central Hospital from l August 2016 to 30 September 2018.All the included patients were classifled into 5 etiologic subtypes based on modified TOAST,and the relationship between the subtypes and risk factors were investigated.Results: Among the 732 IS patients included in this study,the proportion of improved TOAST subtype was:Atherosclerotic thrombosis(AT)subtype 65.6percent,cardiogenic embolism(CE)subtype 11.9 percent,small-artery disease(SAD)subtype 4.1 percent,other clear pathogeny(SOE)1.4 percent,and unexplained(SUE)17.1 percent.There were statistically significant differences in hypertension(x~2 = 13.210 P<0.05)and hyperlipidemia(x~2=9.422 P<0.05)in patients of different improved TOAST types.Conclusions : The improved TOAST typing in South Korea has effectively reduced the proportion of unexplained types,and there are differences between hypertension and hyperlipidemia in IS patients with different causes,which provides a reference basis for individualized treatment and secondary prevention of IS.