JPSIM Journal of Pakistan Society of Internal Medicine J Pak Soc Intern Med 2709-8729 2710-0804 Pakistan Society of Internal Medicine 10.70302/jpsim.v3i3.2248 jpsim.v3i3.2248 Original Research Comparative Effectiveness of Rivaroxaban, Enoxaparin and Aspirin in Patients with Acute Ischemic Stroke Khan Farmanullah Lodhi Sidrah Sidrah.lodhi@gmail.com * Masud Mohsin Abaidullah Sajid Department of Medicine, DHQ Timergara Department of Medicine, King Edward Medical University, Lahore *Correspondence: Sidrah Lodhi (Sidrah.lodhi@gmail.com) 12 09 2022 2022 3 3 242 246 14 04 2022 30 06 2022 Copyright © 2022 The Author(s) 2022 The Author(s) https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective

To compare effectiveness of Rivaroxaban, Enoxaparin and Aspirin therapy in acute ischemic stroke.

 Methodology

This randomized controlled trial in King Edward Medical University, Lahore included 210 patients, aged 18-75 years with acute ischemic stroke within last 24 hours. CT scan brain ruled out any evidence of intracranial bleeding. Functional status was assessed by modified Rankin Score (mRS) at presentation. Patients were randomized to receive 15mg Rivaroxaban, 40mg Enoxaparin twice daily or 300mg aspirin daily for 10 days. Patients were followed up at 14 days for new stroke events and mRS. Absence of major bleed was the safety parameter. Data was analyzed in SPSS 26.0 by ANOVA and chi-square keeping p-value ≤ 0.05 as significant.

 Results

Among the 53.81% male and 46.19% females (total 210 patients), mean age was 60.44±4.48 years. Mean mRS at day 1 was 3.90±0.422, 3.86±0.460 & 3.81±0.460 in Rivaroxaban, Enoxaparin and Aspirin groups respectively (p-value 0.527). Day 14, mRS was 3.81±0.460, 3.80±0.437 & 3.83±0.450 in the three groups respectively (p-value 0.932). New stroke events in 20 cases and favorable outcomes in 190 were evenly distributed among the 3 groups (p-value 0.488). There was major bleeding event.

 Conclusion

Anticoagulants (Rivaroxaban or Enoxaparin) are equivalent to Aspirin without increased risk of significant bleeding in the management of patients with acute ischemic stroke.

 Keywords Acute ischemic stroke Aspirin Enoxaparain. References Akhtar S, Asghar N. Risk factors of cardiovascular disease in district Swat. J Pak Med Assoc. 2015;65(9):1001-4. Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every Newborn: progress, priorities, and potential beyond survival. The Lancet. 2014;384(9938):189-205. Naveed Babur M, Habibullah S, Aftab A. Attitude and perception of physical therapists towards multidisciplinary team aproach in stroke rehabilitation. Pak J Neuro Sci. 2016;11(4):26-30. Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-322. Mapulanga M. Factors influencing patients’ non-compliance with clinical rehabilitation services in a rural African setting. Int J Med Heal Res. 2015;1(1):68-71. Yi X, Lin J, Wang C, Zhang B, Chi W. Low-molecular-weight heparin is more effective than aspirin in preventing early neurologic deterioration and improving six-month outcome. J Stroke Cerebrovasc Dis. 2014;23(6):1537-44. Seto S-W, Chang D, Jenkins A, Bensoussan A, Kiat H. Angiogenesis in ischemic stroke and angiogenic effects of Chinese herbal medicine. J Clin Med. 2016;5(6):56. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2018;49(3):e46-e99. Xu T, Baber U. Acute coronary syndrome. Hosp Med Clin. 2014;3(4):471-8. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344-e418. Yi X, Chi W, Wang C, Zhang B, Lin J. Low-molecular-weight heparin or dual antiplatelet therapy is more effective than aspirin alone in preventing early neurological deterioration and improving the 6-month outcome in ischemic stroke patients. J Clin Neurol. 2015;11(1):57-65. Pleșa CF, Nicolae C, Sirbu CA, Nemeș R, Păunescu A, Țânțu MM. Use of anticoagulants in cerebral vascular pathology. 2019;67(1):27-33. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Eng J Med. 2011;365(10):883-91. Yang F, Jiang W, Bai Y, Han J, Liu X, Zhang G, et al. Treatment of Rivaroxaban versus Aspirin for Non-disabling Cerebrovascular Events (TRACE): study protocol for a randomized controlled trial. BMC Neurol. 2015;15(1):1-7. NHLBI N. Target Levels for Weight Loss. [Updated 2016, cited 2022] Available from [https://www.nhlbi.nih.gov/health/educational/lose_wt/recommen.htm#:~:text=The%20initial%20goal%20of%20weight,the%20amount%20of%20weight%20lost.] Khafagy AT, Hamdy EMH, Yehia MA, Hamdy NA, Shawky NM. Association between Metabolic syndrome and atherothrombotic stroke: A clinical study in Minia University Hospital, Neurology department. Psychiat Neurosurg. 2019;55(1):1-5 Lassen MR, Ageno W, Borris LC, Lieberman JR, Rosencher N, Bandel TJ, et al. Rivaroxaban versus enoxaparin for thromboprophylaxis after total knee arthroplasty. N Eng J Med. 2008;358(26):2776-86. Zannad F, Anker SD, Byra WM, Cleland JG, Fu M, Gheorghiade M, et al. Rivaroxaban in patients with heart failure, sinus rhythm, and coronary disease. N Eng J Med. 2018;379(14):1332-42. Matos JD, Zimetbaum PJ. Controversy surrounding ROCKET-AF: a call for transparency, but should we be changing practice? Arrhythmia Electrophysiol Rev. 2016;5(1):12-13. Harrington AR, Armstrong EP, Nolan Jr PE, Malone DC. Cost-effectiveness of apixaban, dabigatran, rivaroxaban, and warfarin for stroke prevention in atrial fibrillation. Stroke. 2013;44(6):1676-81.