The Treatment Of Aspirin In Combination With Clopidogrel In The Toast Classification Of Ischemic Stroke

Background:Ischemic Stroke (IS) is a neurological deficit of cerebrovascular caused by blood clots suddenly block the blood flow to the brain. IS will have strong adverse effect on the patient’s capability of memory, mathematic/counting, and/or speech, and therefore severely influence the patient’s quality life and wellbeing. IS is one of the major health issues in China due to its high morbidity and mortality. Among all diseases, IS is the first cause of morbidity and the second cause of mortality. Beside of individual’s impact, IS also brings a massive financial burden on the family as well as social health services. The care plan for acute phase IS has already well-established nationally and internationally, although discrepancy on the selection of anti-platelet drugs still exists, especially in using anti-platelet treatment in different TOAST subtypes. This project categorized IS patients by combining the information from CT or MRI brain scanning, head MRA or intracranial/carotid artery ultrasonography, as well as patients’ medical history to establish the pathologically characterization of each IS sub-group and to observe the difference in patients’recovery. Moreover, this project also discussed advantages and limitations of each anti-platelet drugs in treatment of different TOAST groups with an aim to optimize patients’benefits. Further, this project provided an insight of IS onset, progression and recovery to front line neurology clinicians and also suggested strategies of using different anti-platelet drugs in management of TOAST sub-types.Method:According to clinical neurological assessments performed in line with National Institutes of Health Stroke Scale (NIHSS) on the day of admission, ischemic stroke patients in this trial were randomly placed into three arms, aspirin only group with daily intake of aspirin100mg, clopidogrel only group with daily intake of clopidogrel75mg and a combined treatment group with daily intake of100mg aspirin and75mg clopidogrel. All of patients were also given routine treatments including Improve circulation and Neurotrophic as well as control management for blood pressure and blood sugar levels. Moreover, based on individual’s situation, dehydrating agent would be used to reduce intracranial pressure and to ease brain swelling. NIHSS re-assessments were performed on day7, day14after admission, and the patients were followed up over phone at6months and12months. NIHSS scores and incidence of complicities such asbrain blooding werecompared between different treatment groups, as well as amongst TOAST sub-types. Result:1. No difference on baseline NIHSS assessments was observed amongst three treatment groups (p>0.05). Comparing NIHSS scores on day7, day14and at six months after stroke onset found patients with combined treatment achieved a better neurological assessment on day14and at six month after stroke onset comparing to patients using aspirin alone (p<0.05); whereas combined treatment also achieved a better neurological assessment at the end of six month period comparing to patients with clopidogrel only (p<0.05).2. Comparison of NIHSS scores before and after anti-platelet treatments in each TOAST sub-type. In CE group, no significant difference of NIHSS scores on the day of admission, day7, day14and at six months was observed when comparing single drug treatment groups to the combined treatment group (p>0.05). Similarly, in LAA group, no significant difference of NIHSS scores was observed on the day of admission, day7and day14(p>0.05), but for six months’assessment, combined treatment showed a higher efficacy when compared to Aspirin only group (p<0.01), whereas the outcomes of clopidogrel only group were at intermediate with no big difference in contrast to other two groups (p>0.05). In SAA group, there was no difference on NIHSS score on the admission day and day7amongst three treatment arms (p>0.05). However, comparing NIHSS scores on day14and at month six found that the combined treatment having higher efficacy than single anti-platelet treatment (p<0.01), and no difference between two single treatment groups was revealed (p>0.05).3. According to Gusto bleeding scores, no severe blood loss was observed except gum bleeding, which was reported by4(3.8%) cases from aspirin only group,2(3.1%) cases from clopidogrel only group and4(4.4%) cases from the combined treatment group. No significant difference on gum bleeding incidence amongst those three groups.4. Multiple regression analysis on the risk factors of cerebral vascular disease and outcomes of the dual anti-platelet drugs therapies found that the combined treatment provided better clinical endpoints for the IS patient with diabetic history (p<0.05).Conclusion:1. Combined Aspirin and Clopidogrel treatment could significantly improve the neurologic function in IS patients, and short-term admission won’t increase the chance of the side effect such as bleeding.2. For long-term impact, combined treatment delivered better clinical outcomes in LAA and SAA, but not in CE. Moreover, in LAA and SAA, no difference was observed between Aspirin alone group and Clopidogrel group.3. The combined Aspirin and Clopidogrel treatment can significantly improve the neurologic function among the IS patients with type2diabetes.