title: Efficacy of antiplatelet therapy in secondary prevention following lacunar stroke: pooled analysis of randomized trials.
abstract: OBJECTIVE
  Lacunar stroke accounts for ≈25% of ischemic stroke, but optimal antiplatelet regimen to prevent stroke recurrence remains unclear. We aimed to evaluate the efficacy of antiplatelet agents in secondary stroke prevention after a lacunar stroke.
  
  
  METHODS
  We searched MEDLINE, Embase, and the Cochrane library for randomized controlled trials that reported risk of recurrent stroke or death with antiplatelet therapy in patients with lacunar stroke. We used random effects meta-analysis and evaluated heterogeneity with I(2).
  
  
  RESULTS
  We included 17 trials with 42,234 participants (mean age 64.4 years, 65% male) and follow up ranging from 4 weeks to 3.5 years. Compared with placebo, any single antiplatelet agent was associated with a significant reduction in recurrence of any stroke (risk ratio [RR] 0.77, 0.62-0.97, 2 studies) and ischemic stroke (RR 0.48, 0.30-0.78, 2 studies), but not for the composite outcome of any stroke, myocardial infarction, or death (RR 0.89, 0.75-1.05, 2 studies). When other antiplatelet agents (ticlodipine, cilostazol, and dipyridamole) were compared with aspirin, there was no consistent reduction in stroke recurrence (RR 0.91, 0.75-1.10, 3 studies). Dual antiplatelet therapy did not confer clear benefit over monotherapy (any stroke RR 0.83, 0.68-1.00, 3 studies; ischemic stroke RR 0.80, 0.62-1.02, 3 studies; composite outcome RR 0.90, 0.80-1.02, 3 studies).
  
  
  CONCLUSIONS
  Our results suggest that any of the single antiplatelet agents compared with placebo in the included trials is adequate for secondary stroke prevention after lacunar stroke. Dual antiplatelet therapy should not be used for long-term stroke prevention in this stroke subtype.
authors.affiliation: From the Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK (C.S.K.); Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK (C.S.K., P.K.M.); Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.); Department of Surgery, Addenbrooke's Hospital, Cambridge, UK (H.C.C.); Department of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK (Y.K.L.); and Department of Medicine, Brain Research Centre, University of British Columbia, Vancouver Stroke Program, Vancouver, Canada (O.R.B.). shingkwok@doctors.org.uk.
authors.forename: Chun Shing
authors.initials: CS
authors.lastname: Kwok
authors.affiliation: From the Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK (C.S.K.); Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK (C.S.K., P.K.M.); Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.); Department of Surgery, Addenbrooke's Hospital, Cambridge, UK (H.C.C.); Department of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK (Y.K.L.); and Department of Medicine, Brain Research Centre, University of British Columbia, Vancouver Stroke Program, Vancouver, Canada (O.R.B.).
authors.forename: Ashkan
authors.initials: A
authors.lastname: Shoamanesh
authors.affiliation: From the Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK (C.S.K.); Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK (C.S.K., P.K.M.); Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.); Department of Surgery, Addenbrooke's Hospital, Cambridge, UK (H.C.C.); Department of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK (Y.K.L.); and Department of Medicine, Brain Research Centre, University of British Columbia, Vancouver Stroke Program, Vancouver, Canada (O.R.B.).
authors.forename: Hannah Charlotte
authors.initials: HC
authors.lastname: Copley
authors.affiliation: From the Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK (C.S.K.); Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK (C.S.K., P.K.M.); Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.); Department of Surgery, Addenbrooke's Hospital, Cambridge, UK (H.C.C.); Department of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK (Y.K.L.); and Department of Medicine, Brain Research Centre, University of British Columbia, Vancouver Stroke Program, Vancouver, Canada (O.R.B.).
authors.forename: Phyo Kyaw
authors.initials: PK
authors.lastname: Myint
authors.affiliation: From the Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK (C.S.K.); Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK (C.S.K., P.K.M.); Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.); Department of Surgery, Addenbrooke's Hospital, Cambridge, UK (H.C.C.); Department of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK (Y.K.L.); and Department of Medicine, Brain Research Centre, University of British Columbia, Vancouver Stroke Program, Vancouver, Canada (O.R.B.).
authors.forename: Yoon K
authors.initials: YK
authors.lastname: Loke
authors.affiliation: From the Institute of Cardiovascular Sciences, University of Manchester, Manchester, UK (C.S.K.); Institute of Applied Health Sciences, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK (C.S.K., P.K.M.); Department of Medicine, McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada (A.S.); Department of Surgery, Addenbrooke's Hospital, Cambridge, UK (H.C.C.); Department of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, UK (Y.K.L.); and Department of Medicine, Brain Research Centre, University of British Columbia, Vancouver Stroke Program, Vancouver, Canada (O.R.B.).
authors.forename: Oscar R
authors.initials: OR
authors.lastname: Benavente
mesh_terms: D000368:Aged; D001241:Aspirin / Q000494:pharmacology; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010919:Placebos; D010975:Platelet Aggregation Inhibitors / Q000494:pharmacology*; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data*; D012008:Recurrence; D055502:Secondary Prevention / Q000379:methods*; D059409:Stroke, Lacunar / Q000188:drug therapy* / Q000517:prevention & control; D016896:Treatment Outcome
chemical_list: D010919:Placebos; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin
keywords: antiplatelet agent; aspirin; lacunar stroke; mortality; stroke