Priority 9 Stroke Prevention, Diagnosis, Pre-hospital and Hospital Care

UNCERTAINTY: What are the risks and benefits of using blood-thinning treatments (antiplatelet and anticoagulants) to stop stroke happening after TIA or haemorrhagic or ischaemic stroke? Is personalised decision-making possible for the timing and types of antiplatelet and anticoagulant therapy used? (JLA PSP Priority 9)
Overall ranking	9
JLA question ID	0106/9a
Explanatory note	This issue is a central dilemma in stroke treatment. The blood-thinning treatments are considered to be the cornerstone for secondary prevention of stroke (2020 review, see Evidence), however they need to be prescribed widely to see any benefit over the stroke population. There has long been concern over potential increased risk of bleeding due to the medications. Some people don’t respond as they’re resistant, and individual factors such as weight and presence of atrial fibrillation, should be taking into account when advising on secondary prevention treatments (from workshop discussions). The 2020 review explored the evidence for different drug combinations and concluded that further studies are required. There are ongoing trials that might partially address this question However evidence is needed to increase the effectivity of the use of these medications in secondary prevention to improve outcomes.
Evidence	https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008980.pub3/full https://doi.org/10.1002/14651858.CD000024.pub4 https://doi.org/10.1002/14651858.CD009716.pub2 https://doi.org/10.1002/14651858.CD012144.pub2 https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009586.pub3/full?highlightAbstract=screen%7Cscreening%7Caf
Health Research Classification System category	Stroke

Extra information provided by this PSP
Original uncertainty examples	When will there be research comparing novel oral anticoagulants (NOAC) with NOAC as opposed to all being compared with Warfarin? With several on the market it would be useful to know which performs best, so our stroke patients can get the most appropriate medication. ~ Clearer guidelines re use of anticoagulation in AF and timing of initiating this therapy after an acute infarction. Few people wait two weeks as per current guidelines and there is a range of ideas out there as to when it is appropriate to do so. Confusing evidence from 3-14 days depending on infarct size. Clear guidance around what to do with anticoagulation if indication is valvular heart disease would also be welcomed. ~ What is the best management of bleeds that occur while people are receiving apixaban, rivaroxaban or dabigatran etexilate, for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation? ~ Can routine data from UK primary care databases clarify stroke risk in people with atrial fibrillation according to baseline risk factors and treatment?
Submitted by	Health/social care professional x 4, Stroke survivor x 1, Research Recommendation x 28

Extra information provided by this PSP

Original uncertainty examples

When will there be research comparing novel oral anticoagulants (NOAC) with NOAC as opposed to all being compared with Warfarin? With several on the market it would be useful to know which performs best, so our stroke patients can get the most appropriate medication. ~ Clearer guidelines re use of anticoagulation in AF and timing of initiating this therapy after an acute infarction. Few people wait two weeks as per current guidelines and there is a range of ideas out there as to when it is appropriate to do so. Confusing evidence from 3-14 days depending on infarct size. Clear guidance around what to do with anticoagulation if indication is valvular heart disease would also be welcomed. ~ What is the best management of bleeds that occur while people are receiving apixaban, rivaroxaban or dabigatran etexilate, for preventing stroke and systemic embolism in people with nonvalvular atrial fibrillation? ~ Can routine data from UK primary care databases clarify stroke risk in people with atrial fibrillation according to baseline risk factors and treatment?

Submitted by

Health/social care professional x 4, Stroke survivor x 1, Research Recommendation x 28

PSP information
PSP unique ID	0106
PSP name	Stroke prevention, diagnosis, pre-hospital and hospital care
Total number of uncertainties identified by this PSP.	93 (To see a full list of all uncertainties identified, please see the detailed spreadsheet held on the JLA website)
Date of priority setting workshop	30th April 2021