Vitamin K antagonists versus antiplatelet therapy after transient ischaemic attack or minor ischaemic stroke of presumed arterial origin.

People who have had a transient ischaemic attack (TIA) or non-disabling ischaemic stroke have an annual risk of major vascular events of between 4% and 11%. Aspirin reduces this risk by 20% at most. Secondary prevention trials after myocardial infarction indicate that treatment with vitamin K antagonists is associated with a risk reduction approximately twice that of treatment with antiplatelet therapy.

OBJECTIVES: To compare the efficacy and safety of vitamin K antagonists and antiplatelet therapy in the secondary prevention of vascular events after cerebral ischaemia of presumed arterial origin. SEARCH
METHODS: We searched the Cochrane Stroke Group Trials Register (last searched 15 September 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (2008 to September 2011) and EMBASE (2008 to September 2011). In an effort to identify further relevant trials we searched ongoing trials registers and reference lists. We also contacted authors of published trials for further information and unpublished data.
SELECTION CRITERIA: Randomised trials of oral anticoagulant therapy with vitamin K antagonists (warfarin, phenprocoumon or acenocoumarol) versus antiplatelet therapy for long-term secondary prevention after recent transient ischaemic attack or minor ischaemic stroke of presumed arterial origin.
DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed trial quality and extracted data.
MAIN RESULTS: We included eight trials with a total of 5762 participants. The data showed that anticoagulants (in any intensity) are not more efficacious in the prevention of vascular events than antiplatelet therapy (medium intensity anticoagulation: relative risk (RR) 0.80, 95% confidence interval (CI) 0.56 to 1.14; high intensity anticoagulation: RR 1.02, 95% CI 0.49 to 2.13). There is no evidence that treatment with low intensity anticoagulation gives a higher bleeding risk than treatment with antiplatelet agents: RR 1.27 (95% CI 0.79 to 2.03). However, it was clear that medium and high intensity anticoagulation with vitamin K antagonists, with an INR of 2.0 to 4.5, were not safe because they yielded a higher risk of major bleeding complications (medium intensity anticoagulation: RR 1.93, 95% CI 1.27 to 2.94; high intensity anticoagulation: RR 9.0, 95% CI 3.9 to 21).
AUTHORS’ CONCLUSIONS: For the secondary prevention of further vascular events after TIA or minor stroke of presumed arterial origin, there is sufficient evidence to conclude that vitamin K antagonists in any dose are not more efficacious than antiplatelet therapy and that medium and high intensity anticoagulation leads to a significant increase in major bleeding complications.

Comments from Clinical Raters


Internal Medicine

Treatment recommendations for patients following transient ischemic attack or minor ischemic stroke have as a goal the prevention of additional similar episodes without incurring excessive risk for bleeding. We now have significant scientific evidence of the lack of added benefit of vitamin K antagonists used for this purpose as well as their considerable increased risk. Recommendations for antiplatelet therapy can be used for our patients with a greater level of confidence.



I don’t believe this is new information; the vitamin K antagonists will most likely be replaced by the new anticoagulants.


Most neurologists would agree, although the key is the word “presumed” in presumed arterial origin. Anticoagulants are usually reserved for people with presumed cardiogenic embolism presenting as a TIA.


Source: Cochrane Database



Estrogen Plus Progestin and Colorectal Cancer Incidence and Mortality.

During the intervention phase in the Women`s Health Initiative (WHI) clinical trial, use of estrogen plus progestin reduced the colorectal cancer diagnosis rate, but the cancers were found at a substantially higher stage. To assess the clinical relevance of the findings, analyses of the influence of combined hormone therapy on colorectal cancer incidence and colorectal cancer mortality were conducted after extended follow-up. PATIENTS AND METHODSThe WHI study was a randomized, double-blind, placebo-controlled clinical trial involving 16,608 postmenopausal women with an intact uterus who were randomly assigned to daily 0.625 mg conjugated equine estrogen plus 2.5 mg medroxyprogesterone acetate (n = 8,506) or matching placebo (n = 8,102). Colorectal cancer diagnosis rates and colorectal cancer mortality were assessed.ResultsAfter a mean of 5.6 years (standard deviation [SD], 1.03 years) of intervention and 11.6 years (SD, 3.1 years) of total follow-up, fewer colorectal cancers were diagnosed in the combined hormone therapy group compared with the placebo group (diagnoses/year, 0.12% v 0.16%; hazard ratio [HR], 0.72; 95% CI, 0.56 to 0.94; P = .014). Bowel screening examinations were comparable between groups throughout. Cancers in the combined hormone therapy group more commonly had positive lymph nodes (50.5% v 28.6%; P < .001) and were at higher stage (regional or distant, 68.8% v 51.4%; P = .003). Although not statistically significant, there was a higher number of colorectal cancer deaths in the combined hormone therapy group (37 v 27 deaths; 0.04% v 0.03%; HR, 1.29; 95% CI, 0.78 to 2.11; P = .320). CONCLUSIONThe findings, suggestive of diagnostic delay, do not support a clinically meaningful benefit for combined hormone therapy on colorectal cancer.

Comments from Clinical Raters


Nobody is deciding whether to prescribe HRT based on change of risk for colorectal cancer.


Source: JCO



Bilinguals See the World in a Different Way, Study Suggests.

Learning a foreign language literally changes the way we see the world, according to new research. Panos Athanasopoulos, of Newcastle University, has found that bilingual speakers think differently to those who only use one language.

And you don’t need to be fluent in the language to feel the effects — his research showed that it is language use, not proficiency, which makes the difference.

Working with both Japanese and English speakers, he looked at their language use and proficiency, along with the length of time they had been in the country, and matched this against how they perceived the colour blue.

Colour perception is an ideal way of testing bilingual concepts because there is a huge variation between where different languages place boundaries on the colour spectrum.

In Japanese, for example, there are additional basic terms for light blue (mizuiro) and dark blue (ao) which are not found in English.

Previous research has shown that people are more likely to rate two colours to be more similar if they belong to the same linguistic category.

“We found that people who only speak Japanese distinguished more between light and dark blue than English speakers,” said Dr Athanasopoulos, whose research is published in the current edition of Bilingualism: Language and Cognition. “The degree to which Japanese-English bilinguals resembled either norm depended on which of their two languages they used more frequently.”

Most people tend to focus on how to do things such as order food or use public transport when they learn another language to help them get by, but this research has shown that there is a much deeper connection going on.

“As well as learning vocabulary and grammar you’re also unconsciously learning a whole new way of seeing the world,” said Dr Athanasopoulos. “There’s an inextricable link between language, culture and cognition.

“If you’re learning language in a classroom you are trying to achieve something specific, but when you’re immersed in the culture and speaking it, you’re thinking in a completely different way.”

He added that learning a second language gives businesses a unique insight into the people they are trading with, suggesting that EU relations could be dramatically improved if we all took the time to learn a little of each other’s language rather than relying on English as the lingua-franca.

“If anyone needs to be motivated to learn a new language they should consider the international factor,” he said. “The benefits you gain are not just being able to converse in their language — it also gives you a valuable insight into their culture and how they think, which gives you a distinct business advantage.

“It can also enable you to understand your own language better and gives you the opportunity to reflect on your own culture, added Dr Athanasopoulos, who speaks both Greek and English.