Pre-admission antithrombotic use is associated with 3-month mRS score after thrombectomy for acute ischemic stroke

Abstract

In patients who undergo thrombectomy for acute ischemic stroke, the relationship between pre-admission antithrombotic (anticoagulation or antiplatelet) use and both radiographic and functional outcome is not well understood. We sought to explore the relationship between pre-admission antithrombotic use in patients who underwent thrombectomy for acute ischemic stroke at two medical centers in New York City between December 2018 and November 2020. Analyses were performed using analysis of variance and Pearson's chi-squared tests. Of 234 patients in the analysis cohort, 65 (28%) were on anticoagulation, 64 (27%) were on antiplatelet, and 105 (45%) with no antithrombotic use pre-admission. 3-month Modified Rankin Scale (mRS) score of 3-6 was associated with pre-admission antithrombotic use (71% anticoagulation vs. 77% antiplatelet vs. 56% no antithrombotic, p = 0.04). There was no relationship between pre-admission antithrombotic use and Thrombolysis in Cerebral Iinfarction (TICI) score, post-procedure Alberta Stroke Program Early CT Score (ASPECTS) score, rate of hemorrhagic conversion, length of hospital admission, discharge NIH Stroke Scale (NIHSS), discharge mRS score, or mortality. When initial NIHSS score, post-procedure ASPECTS score, and age at admission were included in multivariate analysis, pre-admission antithrombotic use was still significantly associated with a 3-month mRS score of 3-6 (OR 2.36, 95% CI 1.03-5.54, p = 0.04). In this cohort of patients with acute ischemic stroke who underwent thrombectomy, pre-admission antithrombotic use was associated with 3-month mRS score, but no other measures of radiographic or functional outcome. Further research is needed on the relationship between use of specific anticoagulation or antiplatelet agents and outcome after acute ischemic stroke, but moreover, improve stroke prevention.

Effect of chronic antiplatelet therapy on clinical outcomes of endovascular thrombectomy for treatment of acute ischemic stroke

“…9 Among observational studies with smaller sample sizes, a 2022 retrospective study of preadmission antithrombotic use in a cohort of 234 EVTtreated patients in New York City demonstrated no association of APT with extent of reperfusion, postprocedure Alberta Stroke Program Early CT Score (ASPECTS), hemorrhagic conversion, hospital length of stay, discharge NIHSS score, or discharge mRS score, but did report an association with worse outcomes at 3 months (mRS scores 3-6). 10 Finally, an increased adjusted risk of dependence at 90 days and of sICH was demonstrated in patients with chronic APT use in a single-center retrospective analysis of approximately 200 patients in France. 11 Collectively, the existing evidence remains heterogeneous and inconclusive regarding the efficacy and safety of preexisting APT in AIS treated with EVT, although observational studies with larger sample sizes appear to demonstrate equipoise in clinical outcomes and propensity for sICH.…”

Ischaemic stroke despite antiplatelet therapy: Causes and outcomes

“…22 Furthermore, one study compared the incidents of recurrent stroke and/or death at 3 or 12 months respectively, in a post hoc analysis of the NINDS rt-PA and TOAST study cohorts (1275 and 624 patients respectively) and found no difference between patients with and without prior APT. 36 Another two studies found no difference in the mortality rates at 3 months (234 patients) 18 or 12 months (4275 patients) in patients with APT compared to no antithrombotic therapy as well. While one older study found a lower 4-week mortality with prior aspirin use.…”

“…15,33 Whereas some studies showed an unfavourable outcome at 3 months of patients on APT (234 patients 18 ) or no difference regardless of antithrombotic therapy (433 patients, 34 2048 patients 35 ). Besides the significantly larger cohort, the percentage of patients on prior APT was significantly higher in our study (except for one small study 32 ) and different studies defined outcomes differently (favourable mRS 0-1, 32,33 favourable mRS 0-2, 15,18,34 mRS absolute values 14 ). Finally, one US Get-with-the-Guidelines multi-centre registry with more than half a million patients found a favourable functional outcome (mRS 0-1) in patients on prior antithrombotic therapies (APT and AC) compared to no antithrombotic pre-treatment, but this was assessed at hospital discharge and not at 3 months as in our study.…”

“…14 In contrast to our study, in other analyses (260 patients, 32 1862 patients, 33 5700 patients, 15 10,433 patients 14 ) APT was associated with better functional outcome (mRS) at discharge 14,32 or at 3 months. 15,33 Whereas some studies showed an unfavourable outcome at 3 months of patients on APT (234 patients 18 ) or no difference regardless of antithrombotic therapy (433 patients, 34 2048 patients 35 ). Besides the significantly larger cohort, the percentage of patients on prior APT was significantly higher in our study (except for one small study 32 ) and different studies defined outcomes differently (favourable mRS 0-1, 32,33 favourable mRS 0-2, 15,18,34 mRS absolute values 14 ).…”

“…The percentage of patients with ischaemic stroke despite APT in our national stroke registry-based study aligns with previous studies worldwide ranging between 16% and 50% from small single centre or multi-centre studies including a few 100 up to over 90,000 patients. 5,[14][15][16][17][18][19][20][21] However, the vast majority of these studies had been conducted in the early 2000 up to 2015 and only one study reported patients from 2018 but included only 200 patients. Therefore, our study provides the most up-to date information on the prevalence of prior APT in patients with incident ischaemic stroke in the setting of modern antithrombotic therapy including the availability of novel agents (i.e.…”