Dual Antiplatelet Therapy after Intravenous Thrombolysis for Acute Minor Ischemic Stroke

Zhao, Guangjian; Lin, Fan-zhen; Wang, Ziran; Shao, Xiaolin; Gong, Yanxue; Zhang, Shirui; Cui, Yansen; Yang, Dai-Qun; Lei, Hongyan; Cheng, Zhongrong; Wang, Liquan; Guo, Dan; Zhang, Qinghua

doi:10.1159/000505241

Cited by 13 publications

(9 citation statements)

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“…The 0.9% rate of sICH with alteplase in this study was comparable to other studies of Chinese patients with minor stroke who were treated with alteplase (0%-1.0%). 18,19 The strengths of this randomized trial were its large sample size, multicenter recruitment, and dual antiplatelet strategy, which enhances the generalizability of the results. Age, sex, medical history, time from onset of symptoms to treatment, and presumed stroke cause in the trial were similar to routine clinical practice.…”

Section: Discussionmentioning

confidence: 99%

Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke

Chen,

Cui,

Zhou

et al. 2023

JAMA

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ImportanceIntravenous thrombolysis is increasingly used in patients with minor stroke, but its benefit in patients with minor nondisabling stroke is unknown.ObjectiveTo investigate whether dual antiplatelet therapy (DAPT) is noninferior to intravenous thrombolysis among patients with minor nondisabling acute ischemic stroke.Design, Setting, and ParticipantsThis multicenter, open-label, blinded end point, noninferiority randomized clinical trial included 760 patients with acute minor nondisabling stroke (National Institutes of Health Stroke Scale [NIHSS] score ≤5, with ≤1 point on the NIHSS in several key single-item scores; scale range, 0-42). The trial was conducted at 38 hospitals in China from October 2018 through April 2022. The final follow-up was on July 18, 2022.InterventionsEligible patients were randomized within 4.5 hours of symptom onset to the DAPT group (n = 393), who received 300 mg of clopidogrel on the first day followed by 75 mg daily for 12 (±2) days, 100 mg of aspirin on the first day followed by 100 mg daily for 12 (±2) days, and guideline-based antiplatelet treatment until 90 days, or the alteplase group (n = 367), who received intravenous alteplase (0.9 mg/kg; maximum dose, 90 mg) followed by guideline-based antiplatelet treatment beginning 24 hours after receipt of alteplase.Main Outcomes and MeasuresThe primary end point was excellent functional outcome, defined as a modified Rankin Scale score of 0 or 1 (range, 0-6), at 90 days. The noninferiority of DAPT to alteplase was defined on the basis of a lower boundary of the 1-sided 97.5% CI of the risk difference greater than or equal to −4.5% (noninferiority margin) based on a full analysis set, which included all randomized participants with at least 1 efficacy evaluation, regardless of treatment group. The 90-day end points were assessed in a blinded manner. A safety end point was symptomatic intracerebral hemorrhage up to 90 days.ResultsAmong 760 eligible randomized patients (median [IQR] age, 64 [57-71] years; 223 [31.0%] women; median [IQR] NIHSS score, 2 [1-3]), 719 (94.6%) completed the trial. At 90 days, 93.8% of patients (346/369) in the DAPT group and 91.4% (320/350) in the alteplase group had an excellent functional outcome (risk difference, 2.3% [95% CI, −1.5% to 6.2%]; crude relative risk, 1.38 [95% CI, 0.81-2.32]). The unadjusted lower limit of the 1-sided 97.5% CI was −1.5%, which is larger than the −4.5% noninferiority margin (P for noninferiority &lt;.001). Symptomatic intracerebral hemorrhage at 90 days occurred in 1 of 371 participants (0.3%) in the DAPT group and 3 of 351 (0.9%) in the alteplase group.Conclusions and RelevanceAmong patients with minor nondisabling acute ischemic stroke presenting within 4.5 hours of symptom onset, DAPT was noninferior to intravenous alteplase with regard to excellent functional outcome at 90 days.Trial RegistrationClinicalTrials.gov Identifier: NCT03661411

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Section: Discussionmentioning

confidence: 99%

Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke

Chen,

Cui,

Zhou

et al. 2023

JAMA

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“…As a result, many neurologists tend to conservatively use single antiplatelet therapy (aspirin or clopidogrel) for patients with minor stroke who received thrombolysis (31). We noticed an article published by Dr. Zhang (23) in which the authors verified the efficacy and safety of dual antiplatelet therapy after IVT to some extent. They enrolled patients with acute minor ischemic stroke with a NIHSS score ≤ 5.…”

Section: Discussionmentioning

confidence: 96%

“…Nevertheless, both rt-PA thrombolytic therapy and antiplatelet treatment have potential bleeding risks and other complications (19)(20)(21)(22), which are worrying in real-world practice, leading to different strategies of antiplatelet treatment for patients with minor stroke receiving IVT. A previous study reported the safety and efficiency of 21-day dual antiplatelet therapy in patients who received IVT compared with single antiplatelet therapy (23). However, no guidelines or large randomized clinical trials have yet identified an antiplatelet strategy under this scenario.…”

Section: Introductionmentioning

confidence: 99%

Dual Antiplatelet Therapy in Patients With Minor Stroke Receiving Intravenous Thrombolysis

Chen

Sun

et al. 2022

Front. Neurol.

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IntroductionConcern over the potential severe bleeding risk of dual antiplatelet therapy for patients with minor stroke after intravenous thrombolysis (IVT) leads to different antiplatelet strategies in the secondary prevention of stroke. Our aim was to investigate the effect of dual antiplatelet therapy on patients with minor ischemic stroke receiving IVT.MethodsFrom November 2016 to April 2021, a total of 855 consecutive patients who received IVT were observed. We collected and analyzed demographic characteristics, medical history, clinical information, and important time metrics of patients with minor ischemic stroke. Comparative and multivariate logistic regression analyses were used to explore the clinical significance of single or dual antiplatelet therapy after IVT. Propensity score matching analyses (1:1 matching including baseline characteristics of patients) were also performed.ResultsA total of 245 patients were enrolled in the study (118 patients in the single antiplatelet therapy group and 127 patients in the dual antiplatelet group). No significant difference was found in baseline characteristics except stroke etiology (p < 0.001) for patients with minor stroke. The dual antiplatelet group showed a higher proportion of 90-day modified Rankin Scale (mRS) (0–1) than the single antiplatelet group (p = 0.030). Furthermore, patients receiving dual antiplatelet therapy had excellent outcomes (90-day mRS 0–1) after adjustment (odds ratio [OR] 2.76, 95% CI 1.27–6.01, p = 0.010). Other secondary outcomes (recurrent stroke within 90 days, symptomatic intracerebral hemorrhage, and early neurological deterioration) were not significantly different between the two groups. These findings were generally consistent in propensity score analyses.ConclusionsDual antiplatelet therapy may be a potential therapeutic approach in patients with minor stroke receiving IVT. Further randomized controlled trials are required to confirm this finding.

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“…Antiplatelet agents can be recommended as a secondary prevention measure in ischemic stroke (Arnold et al, 2016;Majid et al, 2001;Zhao et al, 2019). However, the use of antiplatelet agents for secondary prevention of ischemic stroke in patient with CKD has not been robustly supported by evidence till date (Kelly & Rothwell, 2019).…”

Section: Antiplatelet Agentsmentioning

confidence: 99%

Cerebro‐renal interaction and stroke

Shah

Jagtap

Sarmah

et al. 2020

Eur J of Neuroscience

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Stroke is an event causing a disturbance in cerebral function leading to death and disability worldwide. Both acute kidney injury and chronic kidney disease (CKD) are associated with an increased risk of stroke and cerebrovascular events. The underlying mechanistic approach between impaired renal function and stroke is limitedly explored and has attracted researchers to learn more for developing therapeutic intervention. Common risk factors such as hypertension, hyperphosphatemia, atrial fibrillation, arteriosclerosis, hyperhomocysteinemia, blood-brain barrier disruption, inflammation, etc. are observed in the general population, but are high in renal failure patients. Also, risk factors like bone mineral metabolism, uremic toxins, and anemia, along with the process of dialysis in CKD patients, eventually increases the risk of stroke. Therefore, early detection of risks associated with stroke in CKD is imperative, which may decrease the mortality associated with it. This review highlights mechanisms by which kidney dysfunction can lead to cerebrovascular events and increase the risk of stroke in renal impairment.

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Dual Antiplatelet Therapy after Intravenous Thrombolysis for Acute Minor Ischemic Stroke

Cited by 13 publications

References 0 publications

Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke

Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke

Dual Antiplatelet Therapy in Patients With Minor Stroke Receiving Intravenous Thrombolysis

Cerebro‐renal interaction and stroke

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