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Titolo:
COLLABORATIVE OVERVIEW OF RANDOMIZED TRIALS OF ANTIPLATELET THERAPY .1. PREVENTION OF DEATH, MYOCARDIAL-INFARCTION, AND STROKE BY PROLONGEDANTIPLATELET THERAPY IN VARIOUS CATEGORIES OF PATIENTS
Autore:
ALTMAN R; CARRERAS L; DIAZ R; FIGUEROA E; PAOLASSO E; PARODI JC; CADE JF; DONNAN G; EADIE MJ; GAVAGHAN TP; OSULLIVAN EF; PARKIN D; RENNY JTG; SILAGY C; VINAZZER H; ZEKERT F; ADRIAENSEN H; BERTRANDHARDY JM; BRAN M; DAVID JL; DRICOT J; LAVENNEPARDONGE E; LIMET R; LOWENTHAL A; MORIAU M; SCHAPIRA S; SMETS P; SYMOENS J; VERHAEGHE R; VERSTRAETE M; ATALLAH A; BARNETT H; BATISTA R; BLAKELY J; CAIRNS JA; COTE R; CROUCH J; EVANS G; FINDLAY JM; GENT M; LANGLOIS Y; LECLERC J; NORRIS J; PINEO GF; POWERS PJ; ROBERTS R; SCHWARTZ L; SICURELLA J; TAYLOR W; THEROUX P; TURPIE AG; WEISEL RD; CUI J; LIU L; PIRK J; BAY C; BOYSEN G; KNUDSEN JB; PETERSEN P; SORENSEN PS; TONNESEN HK; HARJOLA PT; ARCAN JC; BALKAU B; BLANCHARD J; BOISSEL JP; BONEU B; BOUSSER MG; BROCHIER M; CLOAREC M; CRIBIER G; DECHAVANNE M; DROUIN P; ESCHWEGE E; GUIRAUDCHAUMEIL B; HUGONOT R; LEIZOROVICZ A; LORIA Y; MICHAT L; MIROUZE J; PANAK E; PASTEYER J; RASCOL A; REVOL L; ROY M; SELLES J; SLAMA G; STARKMAN C; TEULE M; THIBULT N; VERRY M; ALBERT FW; ANDRASSY K; BREDDIN K; ECKEL R; ENCKE A; FROHLICH J; HARTUNG B; HEISS HW; HESS H; HOFLING B; KRAUSE D; LATTA G; LINKE H; LOEW D; LORENZ R; MIDDLETON K; NOVAK G; OLDENDORF M; PFLUGER N; RAITHEL D; REUTER R; SCHETTLER G; SCHNITKER J; SCHOOP W; STIEGLER H; UBERLA K; VOGEL G; WEBER M; WELBERS I; ZEITLER E; ARAPAKIS G; CHAN T; MOK CK; SZABO R; MISRA NP; REDDY K; FITZGERALD GA; APOLLONIO A; BALSANO F; BASELLINI A; CANDELISE L; CATALANO M; CIAVARELLA N; CIUFFETTI G; COCCHERI S; CORTELLARO M; CORVI G; COTO V; DAVI G; DECATERINA R; DIPERRI T; FIESCHI C; GENTILE R; GREGORATTI L; GRESELE P; LAVEZZARI M; LIBRETTI A; MAGNANI B; NENCI G; PAGANO G; PATRONO C; PEDRINI L; PINI M; PRANDONI P; ROMEO F; ROVELLI F; RUDELLI G; RUVOLO G; SIGNORINI GP; TOGNONI G; VIOLI F; FUJIMORI T; KAGEYAMA M; KATSUMURA T; KITAMURA S; MAEDA K; SUZUKI A; TOHGI H; UCHIYAMA S; UTSUMI H; GARCIA AM; ALGRA A; DENOTTOLANDER GJH; KUPPER AJF; VANGIJN J; HART H; KAPPELLE LJ; KOUDSTAAL PJ; LEMMENS T; LODDER J; PANNEBAKKER M; SERRUYS PW; VANDENBELT A; VANDERMEER J; VANDERVIJGH AB; VERHEUGT FWA; VETH G; DALE J; JOHANNESSEN KA; THAULOW E; POPESCU P; TIBERIU N; AZNAR JRD; ESMATJES E; GUITERAS P; LASIERRA J; LOPEZTRIGO P; ORIOL A; POMAR L; ROCHA E; SANCHEZ FD; SANCHORIEGER J; SANZ G; BERGLUND ULF; BLOMSTRAND C; BOBERG M; BRITTON M; ELWIN CE; HELMERS C; HOLM J; JANZON L; JUULMOLLER S; MULEC H; OLSSON JE; PERSSON S; RASMANIS G; ROSEN A; SAMUELSSON K; SOREFF J; WAHLGREN N; WALLENTIN L; BAUR HR; BOKSLAG M; BOLLINGER A; MEIER B; PFISTERER M; PFLUGER N; SITTHIAMORN C; ACHESON EJ; APPLEBY P; ASSCHER AW; AUKLAND A; BAIGENT C; BALA S; BARNETT AH; BELL P; BEWS S; BORN GVR; BRANAGAN JP; BROOKS N; BROWN MJ; BROWSE NL; CAPILDEO R; CARMALT M; CARTER AE; CHALMERS I; CLARKE M; CLARKE RJ; CLYNE CAC; COLLINS R; COOKE ED; COUTTS G; COVE DH; CROWTHER PS; CUTHBERTSON WF; DEBONO D; DICKERSON C; DICKINSON JP; DOLL R; DORMANDY JA; DUNBABIN D; ELL S; ELPHINSTONE P; ELWOOD P; ENGLISHBY V; FARRELL B; FISKERSTRAND C; FLATHER M; FOLEY T; FOULDS T; FOX KM; FRANKS P; FRASER H; GARDECKI T; GAWEL M; GENT AE; GERSHLICK AH; GODWIN J; GOLDMAN M; GRAY C; GRAY D; GRAY R; HANDOLL H; HANKEY G; HARRISON MJG; HENDERSON N; HEPTINSTALL S; HOBBIGER SF; JONES EW; JONES NAG; JOST S; JULIAN D; KELLETT J; KESTER RC; LOWE G; MACKENZIE J; MCCOLLUM CN; MEAD G; MEADE TW; MENDELOW D; MILLER JC; MORRIS GK; NICHOL C; NOBLE M; OBRIEN JR; OGIER M; PARISH S; PARRY MJ; PETO R; POWELL J; POZZILLI P; QIZILBASH N; RAHMAN A; RAJAH SM; RICHARDS DH; RICHARDS S; RIPLEY R; ROBERTS VC; ROSE FC; RUSSELL RWR; RUBIN PC; RUCKLEY CV; SANDERCOCK P; SHAW MDM; SHAW KM; SHELLEY JH; SLATTERY J; SLEIGHT P; SMITH SJ; STEWARTLONG P; SWEETNAM PM; TANSEY MJB; TINDALL H; TURNEY J; TYLER HM; VAREY NC; VESSEY MP; WALKER MG; WALKER MA; WARLOW CP; WILCOX RG; WILLEMS H; WOOD EH; WYNJONES E; ADAMS HP; BARTON B; BEDFORD RF; BICK BL; BINGHAM S; BROWN BG; BRYANT T; BURING J; CABOT CF; CANNER P; CHESEBRO J; CHRISMAN OD; CLAGETT GP; COLWELL JA; DYKEN M; ELLIS D; FIELDS WS; FURBERG C; FUSTER V; GOLDMAN S; GRANETT J; GREEN RM; GREEN D; HARDY R; HARKER LA; HARRIS WH; HART RG; HASS WK; HENNEKENS C; HILL D; HUME M; IGLOE MC; JOHNSON G; JONAS S; KNATTERUD G; KOHLER TR; LEMBO NJ; LEWIS D; LOCKHART E; MAJERUS P; MCENANY MT; MCKENNA R; MEHTA JL; MEYER JS; MOLONY B; MORITZ T; NICOLOFF DM; NYCZ G; ONO H; PANTELY GA; PHILLIPS SJ; RIDKER P; ROBERTSON JT; ROTHBART R; SALZMAN EW; SAUTTER RD; SCHLANT RC; SCHOENBERGER JA; SENGEKONTACKET MV; SHARMA G; STEELE P; STEINNAGEL KP; STRATTON J; SULLIVAN JM; TIMMIS G; TOOLE JF; WALKER MD; WEISMAN S; WHITE CW; WIRECKI M; WOMBOLT D; WONG R; YUSUF S; ZADINA K; ZUCKER D;
Titolo Testata:
BMJ. British medical journal
fascicolo: 6921, volume: 308, anno: 1994,
pagine: 81 - 100
SICI:
0959-8138(1994)308:6921<81:COORTO>2.0.ZU;2-V
Fonte:
ISI
Lingua:
ENG
Soggetto:
LOW-DOSE ASPIRIN; CORONARY-ARTERY BYPASS; TRANSIENT ISCHEMIC ATTACKS; PLACEBO-CONTROLLED TRIAL; VEIN-GRAFT PATENCY; STABLE ANGINA-PECTORIS; DOUBLE-BLIND TRIAL; THROMBOXANE SYNTHETASE INHIBITION; ARTERIOVENOUS-SHUNT THROMBOSIS; CANADIAN AMERICAN TICLOPIDINE;
Tipo documento:
Review
Natura:
Periodico
Settore Disciplinare:
Science Citation Index Expanded
Citazioni:
433
Recensione:
Indirizzi per estratti:
Citazione:
R. Altman et al., "COLLABORATIVE OVERVIEW OF RANDOMIZED TRIALS OF ANTIPLATELET THERAPY .1. PREVENTION OF DEATH, MYOCARDIAL-INFARCTION, AND STROKE BY PROLONGEDANTIPLATELET THERAPY IN VARIOUS CATEGORIES OF PATIENTS", BMJ. British medical journal, 308(6921), 1994, pp. 81-100

Abstract

Objective-To determine the effects of ''prolonged'' antiplatelet therapy (that is, given for one month or more) on ''vascular events'' (non-fatal myocardial infarctions, non-fatal strokes, or vascular deaths) in various categories of patients. Design-Overviews of 145 randomised trials of ''prolonged'' antiplatelet therapy versus control and 29 randomised comparisons between such antiplatelet regimens. Setting-Randomised trials that could have been available by March 1990. Subjects-Trials of antiplatelet therapy versus control included about 70 000 ''high risk'' patients (that is, with some vascular disease or other condition implying an increased risk of occlusive vascular disease) and 30 000 ''low risk'' subjects from the general population. Direct comparisons of different antiplatelet regimens involved about 10 000 high risk patients. Results-In each of four main high risk categories of patients antiplatelet therapy was definitely protective. The percentages of patients suffering a vascular event among those allocated antiplatelet therapy versus appropriately adjusted control percentages (and mean scheduled treatment durations and net absolute benefits) were: (a) amongabout 20 000 patients with acute myocardial infarction, 10% antiplatelet therapy v 14% control (one month benefit about 40 vascular events avoided per 1000 patients treated (2P<0.00001)); (b) among about 20000patients with a past history of myocardial infarction, 13% antiplatelet therapy v 17% control (two year benefit about 40/1000 (2P<0.00001)); (c) among about 10000 patients with a past history of stroke or transient ischaemic attack, 18% antiplatelet therapy v 22% control (three year benefit about 40/1000 (2P<0.00001)); (d) among about 20000 patients with some other relevant medical history (unstable angina, stable angina, vascular surgery, angioplasty, atrial fibrillation, valvular disease, peripheral vascular disease, etc), 9% v 14% in 4000 patients with unstable angina (six month benefit about 5011000 (2P<0.00001)) and 6% v 8% in 16000 other high risk patients (one year benefit about 20/1000 (2P < 0.00001)). Reductions in vascular events were about one quarter in each of these four main categories and were separately statistically significant in middle age and old age, in men and women, in hypertensive and normotensive patients, and in diabetic and nondiabetic patients. Taking all high risk patients together showed reductions of about one third in non-fatal myocardial infarction, about one third in non-fatal stroke, and about one sixth in vascular death (each 2P<0.00001). There was no evidence that non-vascular deaths were increased, so in each of the four main high risk categories overall mortality was significantly reduced. The most widely tested antiplatelet regimen was ''medium dose'' (75-325 mg/day) aspirin. Doses throughout this range seemed similarly effective (although in an acute emergency it might be prudent to use an initial dose of 160-325 mg rather than about 75 mg). There was no appreciable evidence that either a higher aspirin dose orany other antiplatelet regimen was more effective than medium dose aspirin in preventing vascular events. The optimal duration of treatmentfor patients with a past history of myocardial infarction, stroke, ortransient ischaemic attack could not be determined directly because most trials lasted only one, two, or three years (average about two years). Nevertheless, there was significant (2P<0.0001) further benefit between the end of year 1 and the end of year 3, suggesting that longertreatment might well be more effective. Among low risk recipients of ''primary prevention'' a significant reduction of one third in non-fatal myocardial infarction was, however, accompanied by a non-significant increase in stroke. Furthermore, the absolute reduction in vascular events was much smaller than for high risk patients despite a much longer treatment period (4.4% antiplatelet therapy v 4.8% control; five year benefit only about four per 1000 patients treated) and was not significant (2P=0.09).Conclusions-Among a much wider range of patients athigh risk of occlusive vascular disease than is currently treated routinely, some years of antiplatelet therapy-with aspirin 75-325 mg/day or some other antiplatelet regimen (provided there are no contraindications)-offers worthwhile protection against myocardial infarction, stroke, and death. Significant benefit is evident not only among patientswith unstable angina, suspected acute myocardial infarction, or a past history of myocardial infarction, stroke, or transient ischaemic attack, but also among many other categories of high risk patients (such as those having vascular procedures and those with stable angina or peripheral vascular disease). There is as yet, however, no clear evidence on the balance of risks and benefits of antiplatelet therapy in primary prevention among low risk subjects.

ASDD Area Sistemi Dipartimentali e Documentali, Università di Bologna, Catalogo delle riviste ed altri periodici
Documento generato il 25/11/20 alle ore 07:34:08