2 Drugs May Cut Strokes in High-Risk Group

Adding another "blood thinner" to aspirin may reduce the risk of a new stroke in people who have had a very minor or brief stroke, a study finds. The study included more than 5,000 people. All of them had either a "mini-stroke" (with only minor symptoms) or a transient ischemic attack (TIA). With a TIA, stroke symptoms last less than 24 hours. But people who had TIAs in this study also had extra factors that increased their stroke risk. People were randomly divided into 2 groups. One group took aspirin only. The other group took aspirin plus another drug to prevent clotting, clopidogrel (Plavix). In the next 90 days, 8.2% of the 2-drug group and 11.7% of the aspirin-only group had strokes. That's a risk reduction of about one-third for those who took both drugs. They did not have any more side effects, such as excess bleeding, than the aspirin-only group. The New England Journal of Medicine published the study June 26. HealthDay News and MedPage Today wrote about it.

By Robert H. Shmerling, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

A stroke is a bit like a heart attack. In both conditions, blood flow is interrupted. This leads to tissue damage. With a stroke, it's the brain, not the heart, that's injured.

The effects of a stroke depend on its location and size. For some, the problem is movement -- an arm, leg or both become weak. Other strokes affect speech, memory or personality. Some people recover from stroke, in part or completely. Yet it remains a leading cause of disability and death.

One important way to reduce the risk of stroke is to change any factors that increase your risk. We'll get to this shortly. Another way is to begin treatment right away. Medicines that reduce clotting (often called "blood thinners") may lower the risk of stroke if started as soon as symptoms begin.

The New England Journal of Medicine just published a study about this type of treatment. It included more than 5,000 people in China. Each of them had a "mini-stroke" (a stroke with minor symptoms) or a "high-risk" transient ischemic attack. TIA symptoms go away within 24 hours. A high-risk TIA is one that occurs in a person who has multiple factors that increase stroke risk.

Each person in the study received either standard treatment with aspirin or 2 drugs, aspirin and clopidogrel (Plavix). These were given within 24 hours of the start of symptoms.

After 90 days, those receiving both drugs:

• Had a lower rate of stroke (8.2%) than the aspirin-only group (11.7%).
• Had a low rate of serious side effects, including bleeding in the brain or elsewhere. Rates were similar to those of people treated with aspirin alone.

If other studies confirm these results, it could lead to a change in practice that prevents thousands of strokes worldwide.

However, the results may not apply to everyone with stroke symptoms. For example:

• The researchers had to screen more than 40,000 patients to enroll the 5,170 people with a mini-stroke or high-risk TIA.
• The study excluded people with low-risk TIAs and large strokes. Larger strokes are more likely to bleed, especially if blood thinners are taken.
• Study results may vary in ethnic groups with a different genetic makeup or different types of heart disease.

The study also lasted only 90 days. Longer-term follow-up will be important to know whether the advantages of two-drug treatment last.

What Changes Can I Make Now?

When it comes to stroke, the most important changes you can make now are to:

• Know the risk factors for stroke
• Take steps to change any factors that increase your risk
• Know the symptoms of stroke
• Have a plan to get rapid treatment if you develop these symptoms

The most important risk factors for stroke (and ways you can reduce them) include:

• Lack of physical activity -- Exercise for at least 45 minutes most days of the week.
• Smoking -- Quitting should be a priority.
• High blood pressure (hypertension) -- Have your blood pressure taken. If it's high, limit your salt intake and lose excess weight. If necessary, take medicines your doctor recommends.
• Diabetes -- Tight control of your blood sugar may lower your risk of other health problems, including stroke.
• High cholesterol -- If your cholesterol levels are not in an ideal range, talk to your doctor about how to improve them.
• Obesity – Excess weight increases the risk of diabetes, high blood pressure and other risk factors for stroke. It's helpful to maintain a healthy weight.
• Atrial fibrillation -- If you have this abnormal heart beat, consider taking a blood thinner, such as warfarin (Coumadin). Aspirin and/or clopidogrel are usually not enough. Talk to your doctor about the risks and benefits of warfarin and other medicines to treat atrial fibrillation.
• Carotid artery narrowing -- These arteries in the neck supply blood to the brain. If they are narrowed by atherosclerosis, a surgical procedure can open them up, reducing stroke risk. Aspirin treatment may also be helpful.

Advanced age and a family history of heart and blood vessel disease also increase stroke risk. But they can't be changed.

Stroke symptoms come on suddenly. Some of the most common include:

• Weakness or numbness of one arm, one leg or one side of the face
• Difficulty with walking or balance
• Confusion, difficulty with speaking or understanding language
• Blindness or other vision problems
• A new, severe headache

Finally, it is important to know what to do if stroke symptoms develop.

• Have emergency phone numbers handy.
• Know which hospitals are closest to your home and work.
• Discuss a plan of action with those who are close to you.
• When in doubt, call an ambulance, rather than transporting yourself to the hospital.

What Can I Expect Looking to the Future?

If confirmed by future research, this new study could change the treatment of stroke symptoms. Aspirin and clopidogrel could become a more common treatment for stroke. As our population ages, the importance of preventing stroke and treating early symptoms will become even greater than it is now.