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Antiplatelet treatment is well established in the secondary prevention of ischemic cerebrovascular events. The reasons for the occurrence of stroke, even though the patient receives drug treatment, have remained unclear. We performed a subgroup analysis of the European Stroke Prevention Study (ESPS 1) to investigate the efficacy of treatment in patients with different cardiovascular risk factors. The ESPS 1 recruited 1306 patients with TIA, RIND or stroke in one single center of Kuopio in Finland. The patients were treated with aspirin 990 mg/day+dipyridamole 225 mg/day or placebo for 2 years or until an endpoint. The endpoints were stroke or death from any cause. The risk factors for endpoints were analyzed by Cox univariate regression analyses. The effect of a single risk factor on the efficacy of antiplatelet therapy was analyzed by Cox proportional hazards model in subgroups according to the significant risk factors found in the univariate analysis. The efficacy of treatment was statistically significant in all subgroups except diabetics and current smokers for the stroke endpoint. When the combined endpoint of stroke or death was used, the treatment failed also to show statistical significance in patients with coronary heart disease. This lack of efficacy might be due to the small sample size. The efficacy of treatment was significantly better in TIA patients than in stroke patients when analyzed with stroke as an end point. This study provides strong evidence that the effectiveness of antiplatelet treatment in ischemic stroke and TIA patients is independent of most cardiovascular risk factors. Furthermore, all patients with TIA and ischemic stroke should receive secondary prevention regardless of whether or not there are risk factors.

The European Stroke Prevention Study was a multicenter study comparing the effect of the combination of dipyridamole, 75 mg, and acetylsalicylic acid, 330 mg, three times a day, to that of placebo in 2,500 patients in the secondary prevention of stroke or death after one or more transient ischemic attacks, reversible ischemic neurological deficits, or strokes of atherothrombotic origin. The patients with vertebrobasilar events at entry comprised one-third of the whole patient population. The overall total incidence of stroke or death (the end points) during the 2-year follow-up in the placebo group was lower in the vertebrobasilar group compared to the carotid group (14% versus 24%, respectively). The combination therapy of dipyridamole and acetylsalicylic acid caused a marked reduction in the incidence of stroke or death in patients with vertebrobasilar (51%) and carotid (30%) events. When only stroke was considered as the end point, dipyridamole and acetylsalicylic acid seemed to be more effective in reducing the risk of transient ischemic attacks than stroke, and more effective in men than in women.