Antiplatelet regimens for Asian patients with ischemic stroke or transient ischemic attack: a systematic review and network meta-analysis

BACKGROUND: The optimal antiplatelet treatment for the secondary prevention of non-cardioembolic stroke or transient ischemic attack (TIA) remains uncertain in Asians. METHODS: We searched for eligible randomized control trials in Medline, Embase, and the Cochrane Library. A Bayesian network meta-analysis (NMA) was performed to assess the efficacy and safety of antiplatelet regimens with placebo as the control. Each therapy was compared using relative risk ratios (RR) and 95% credible intervals (CrI), and ranked according to the value of the surface under the cumulative ranking curve. RESULTS: A total of 84,103 patients from 32 studies were included: patients in used aspirin (n=26,834); cilostazol (n=3,303); clopidogrel (n=12,406); prasugrel (n=1,885); sarpogrelate (n=752); ticagrelor (n=1,933); ticlopidine (n=1,644); triflusal (n=391); aspirin plus cilostazol (n=1,120), aspirin plus clopidogrel (n=4,623); aspirin plus dipyridamole (n=10,853); aspirin plus ticagrelor (n=5,859); aspirin plus ticlopidine (n=132). Patients who used aspirin plus clopidogrel and cilostazol had a lower risk of recurrent stroke than those who used placebo. Patients administered with aspirin plus ticagrelor, aspirin plus clopidogrel, and cilostazol had a lower risk of composite vascular events than those administered placebo. Patients administered aspirin plus ticagrelor had a higher risk of major bleeding than those administered placebo. Clustered three-dimensional rank plots of recurrent stroke, major bleeding, and composite vascular events demonstrated that cilostazol had higher values of the surface under the cumulative ranking curve than other treatments. CONCLUSIONS: Of the antiplatelet regimens, cilostazol showed the best net clinical benefits than other antiplatelet regimens in Asians with non-cardioembolic stroke or TIA.