Abstract
We’d like to thank Raffaelle Ornello and Matteo Foschi for their interest in our work and their comments and suggestions raised in their letter to the editor.
The 6-month follow-up of the TREAT-CAD trial is an observational extension of the randomized, open-label, non-inferiority main study, 1 which reported on the composite outcome 3 months after symptomatic cervical artery dissection stratified by the type of antithrombotic treatment – that is, aspirin or anticoagulation with vitamin K antagonists (with heparin recommended until target INR is reached). The extended follow-up study has demonstrated that outcome events were rare between 3 and 6 months: only 4 outcome events were observed. More importantly, all of them were hemorrhagic and most of them were pure imaging outcomes. In line with Ornello & Foschi, we conclude that these findings do not justify deviating from the recommendation outlined in current guidelines, suggesting a treatment duration of at least 3 to 6 months. 2 These recommendations are mainly based on expert opinion. The randomized-controlled TREAT-CAD 1 and CADISS 3 studies as well as the large-scale observational STOP-CAD 4 (>3600 patients, follow-up until 6 months) and IPSYS 5 (>1300 patients, median follow-up time in patients without event 36 months), consistently demonstrated an initial high risk of ischemic stroke which declines over time and at least within the first 3 months ischemic events outnumbered hemorrhagic outcomes under antithrombotic treatment. Interestingly, in the observational IPSYS cohort study by Pezzini et al. 5 discontinuation of antithrombotic treatment in the post-acute phase after 6 months did not increase the rate of ischemic events.
These findings indicate that the optimal duration of antithrombotic treatment has yet to be determined, which might vary with individual patient risk profiles. 4 Adequately designed and powered trials are mandatory to answer these questions.
Footnotes
Acknowledgements
None.
Declaration of conflicting interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: LSE reports no relevant disclosures. JEK reports no relevant disclosures. CT reports grants from Swiss Heart Foundation, University of Basel, Bangerter-Rhyner Foundation, and Freiwillige Akademische Gesellschaft Basel; and travel honoraria from Bayer, outside of the submitted work. All other authors declare no competing interests. STE reports grants from Swiss National Science Foundation, Swiss Heart Foundation, Freiwillige Akademische Gesellschaft Basel, University of Basel, the University Hospital Basel, and the Science Fund Rehabilitation of the University Department of Geriatric Medicine Felix Platter Basel during the conduct of the study.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical approval
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Informed consent
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Guarantor
Lukas S Enz.
Contributorship
LSE drafted the manuscript, JEK, CT and STE revised it for intellectual content.
