Higher early recurrence risk and potential benefit of dual antiplatelet therapy for minor stroke with watershed infarction: subgroup analysis of CHANCE

2020 ◽  
Vol 27 (5) ◽  
pp. 800-808
Author(s):  
Y. Pu ◽  
X. Liu ◽  
Y. Wang ◽  
X. Meng ◽  
J. Jing ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Subgroup Analysis ◽  
Potential Benefit ◽  
Dual Antiplatelet Therapy ◽  
Recurrence Risk ◽  
Early Recurrence ◽  
Minor Stroke ◽  
Watershed Infarction

scholarly journals Comparison of outcome of patients with acute minor ischaemic stroke treated with intravenous t-PA, DAPT or aspirin

2020 ◽  
pp. svn-2019-000319
Author(s):  
Peng Wang ◽  
Mengyuan Zhou ◽  
Yuesong Pan ◽  
Xia Meng ◽  
Xingquan Zhao ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
National Institutes Of Health ◽  
Minor Stroke ◽  
Post Hoc Analysis ◽  
Intravenous Tissue Plasminogen Activator ◽  
Tissue Plasminogen ◽  
Ischemic Attack ◽  
Post Hoc

BackgroundWhether to treat minor stroke with intravenous tissue plasminogen activator (t-PA) treatment or antiplatelet therapy is a dilemma. Our study aimed to explore whether intravenous t-PA treatment, dual antiplatelet therapy (DAPT) and aspirin have different efficacies on outcomes in patients with minor stroke.MethodsA post hoc analysis of patients with acute minor stroke treated with intravenous t-PA within 4.5 hours from a nationwide multicentric electronic medical record and patients with acute minor stroke treated with DAPT and aspirin from the Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack Database. Minor stroke was defined by a score of 0–3 on the National Institutes of Health Stroke Scale at randomisation. Favourable functional outcome (defined as modified Rankin Scale (mRS) score of 0–1 or 0–2 at 3 months).ResultsCompared with those treated with intravenous t-PA, no significant association with 3-month favourable functional outcome (defined as mRS score of 0–1) was found neither in patients treated with aspirin (87.8% vs 89.4%; OR, 0.83; 95% CI, 0.46 to 1.50; p=0.53) nor those treated with DAPT (87.4% vs 89.4%; OR, 0.84; 95% CI, 0.46 to 1.52; p=0.56). Similar results were observed for the favourable functional outcome defined as mRS score of 0–2 at 3 months.ConclusionsIn our study, no significant advantage of intravenous t-PA over DAPT or aspirin was found. Due to insufficient sample size, our study is probably unable to draw such a conclusion that that intravenous t-PA was superior or non-superior to DAPT.

Abstract 104: Disability After Minor Stroke and TIA in the POINT Trial

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Brett L Cucchiara ◽  
Jordan Elm ◽  
J Donald Easton ◽  
Shelagh Coutts ◽  
Joshua Willey ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Adverse Events ◽  
Antiplatelet Therapy ◽  
Primary Outcome ◽  
Dual Antiplatelet Therapy ◽  
Recurrent Stroke ◽  
Primary Outcome Measure ◽  
Minor Stroke ◽  
Serious Adverse Events ◽  
Index Event

Background and Purpose: To assess the effect of combination antiplatelet therapy with aspirin and clopidogrel versus aspirin alone on disability following TIA or minor stroke and to identify factors associated with disability. Methods: The POINT trial randomized patients with TIA or minor stroke (NIHSS≤3) within 12 hours of onset to dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel versus aspirin alone. The primary outcome measure was a composite of stroke, MI, or vascular death. We performed a post-hoc exploratory analysis to examine the effect of treatment on overall disability (defined as mRS>1) at 90 days as well as disability ascribed by the local investigator to index or recurrent stroke. We also evaluated predictors of disability. Results: At 90 days, 188/1964 (9.6%) of patients enrolled with TIA and 471/2586 (18.2%) of those enrolled with stroke were disabled. Overall disability was similar between patients assigned DAPT versus aspirin alone (14.7% vs. 14.3%, OR 0.97, 95%CI 0.82-1.14, p=0.69). However, there were numerically fewer patients with disability in conjunction with a primary outcome event in the DAPT arm (3.0% vs. 4.0%, OR 0.73, 95%CI 0.53-1.01, p=0.06), and significantly fewer patients in the DAPT arm with disability attributed by the investigators to either the index event or recurrent stroke (5.9% vs. 7.4%, OR 0.78, 95% CI 0.62-0.99, p=0.04). Notably, disability attributed to the index event accounted for the majority of this difference (4.5% vs. 6.0%, OR 0.74 95% CI 0.57-0.96, p=0.02). In multivariate analysis of patients enrolled with TIA, disability was significantly associated with age, subsequent ischemic stroke, serious adverse events, and major bleeding. In patients enrolled with stroke, disability was associated with female sex, hypertension, diabetes, NIHSS score, recurrent ischemic stroke, subsequent myocardial infarction, and serious adverse events. Conclusions: In addition to reducing recurrent stroke in patients with acute minor stroke and TIA, dual antiplatelet therapy might reduce stroke-related disability.

Lp-PLA2 and dual antiplatelet agents in intracranial arterial stenosis

Neurology ◽  
2019 ◽  
Vol 94 (2) ◽  
pp. e181-e189 ◽  
Author(s):  
Ming Yang ◽  
Anxin Wang ◽  
Jiejie Li ◽  
Xingquan Zhao ◽  
Liping Liu ◽  
...  
Keyword(s):  
High Risk ◽  
Antiplatelet Therapy ◽  
Proportional Hazards ◽  
Dual Antiplatelet Therapy ◽  
Cox Proportional Hazards ◽  
Arterial Stenosis ◽  
Minor Stroke ◽  
Activity Levels ◽  
Intracranial Arterial Stenosis ◽  
Vascular Events

ObjectiveTo evaluate the interaction effect of lipoprotein-associated phospholipase A2 (Lp-PLA2) activity on the efficacy and safety of dual/single antiplatelet therapy in patients with and without intracranial arterial stenosis (ICAS) by the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events trial.MethodsPatients with both MRI analysis and Lp-PLA2 testing results were included in the current subanalysis. The interaction of Lp-PLA2 activity with the effects of dual and single antiplatelet therapy were analyzed through Cox proportional hazards regressions model.ResultsAmong the 797 patients, the mean age was 63.1 ± 10.8 years, 518 (65%) were men, 356 (44.7%) had ICAS, and 441 (55.3%) did not. There were significantly more patients with elevated Lp-PLA2 activity in the ICAS group than in the non-ICAS group (43.8% vs 35.4%, p = 0.02). There was significant interaction between Lp-PLA2 activity levels and the 2 antiplatelet therapies for prevention of stroke recurrences and combined vascular events even after adjustment for confounding factors exclusively for patients with ICAS (p = 0.017, 0.017, respectively), but not for those without (p = 0.332, 0.674, respectively). Compared with aspirin alone, dual antiplatelet therapy significantly reduced the risk of stroke recurrences and combined vascular events (adjusted hazard ratio 0.33 [0.12–0.89], p = 0.028; 0.33 [0.12–0.89], p = 0.028, respectively) for patients with ICAS and nonelevated Lp-PLA2 activity.ConclusionsPresence of both ICAS and nonelevated Lp-PLA2 activity may predict better response to dual antiplatelet therapy in prevention of recurrent strokes and combined vascular events for patients with minor stroke or high-risk TIA.Clinicaltrials.gov identifierNCT00979589.

Abstract WP420: Clopidogrel with Aspirin May be More Effective in Decreasing One-year Stroke Recurrence for Acute Minor Stroke with Watershed Infarcts: Subgroup Analysis of Chance

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Yuehua Pu ◽  
Liping Liu ◽  
Yilong Wang ◽  
Jing Jing ◽  
Anxin Wang ◽  
...  
Keyword(s):  
High Risk ◽  
Mr Imaging ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Minor Stroke ◽  
Stroke Recurrence ◽  
Imaging Data ◽  
Stroke Patients ◽  
One Year ◽  
Watershed Infarcts

Background and Objective: In symptomatic cerebral large artery disease, watershed infarcts may result from hemodynamic impairment or microembolism. Such patients often have a high risk of recurrence or deterioration. It is still not clear whether dual antiplatelet therapy reduce the risk of stroke recurrence. The aim of this subgroup analysis is to discuss whether dual antiplatelet therapy could decrease the one year stroke recurrence more effectively for minor stroke patients with watershed infarcts. Methods: Patients enrolled in Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial and have magnetic resonance (MR) imaging data were included in this study. Diffusion-weighted imaging was obtained for detection of watershed infarcts. We assessed the interaction of the treatment effects of clopidogrel plus aspirin versus aspirin alone among patients with watershed infarcts or not. Results: Of the 1089 patients with MR imaging data enrolled in the CHANCE trial, 831 (76.3%) patients with acute infarcts. Among patients with acute infarcts, 93 (11.19%) were watershed infarcts, 55 (59.14%) received dual antiplatelet therapy. Patients with watershed infarcts had higher rates of recurrent stroke (17.20% vs 10.70%, p=0.063) at 1 year. For patients with watershed infarcts, one-year stroke recurrence was 6 (10.91%) in clopidogrel plus aspirin group and 10 (26.32%) in placebo plus aspirin group. There was interaction between antiplatelet therapy and presence of watershed infarcts on the primary outcome of any stroke (p=0.0933). (Kaplan-Meier curves were showed in the figure). Conclusions: For minor stroke patients with watershed infarcts, clopidogrel with aspirin may be more effective in decreasing 1-year stroke recurrence attributed to its potential mechanism of microembolism. Studies in other populations and subsequent analysis with adequate power are warranted to further verify such findings.

scholarly journals Antiplatelet Therapy in Acute Mild-Moderate Ischemic Stroke (ATAMIS): a parallel, randomised, open-label, multicentre, prospective study

2018 ◽  
Vol 3 (4) ◽  
pp. 263-267 ◽  
Author(s):  
Xiaowen Hou ◽  
Xiaoqiu Li ◽  
Xinhong Wang ◽  
Huisheng Chen
Keyword(s):  
Adverse Events ◽  
Ischaemic Stroke ◽  
Antiplatelet Therapy ◽  
Rational Design ◽  
Dual Antiplatelet Therapy ◽  
Prospective Trial ◽  
Minor Stroke ◽  
Efficacy And Safety ◽  
Open Label ◽  
Nihss Score

BackgroundA recent study shows that dual antiplatelet therapy with clopidogrel plus aspirin is superior to aspirin monotherapy for minor stroke, which is defined as a National Institutes of Health Stroke Scale (NIHSS)score of ≤3. However, acute mild-moderate ischaemic stroke (4≤NIHSS≤10) still needs aggressive antiplatelet intervention to prevent deterioration and recurrence of stroke. The efficacy and safety of dual antiplatelet therapy versus aspirin monotherapy in the population are not clear. A multicentre clinical trial is designed to evaluate the efficacy and safety of clopidogrel plus aspirin therapy versus aspirin monotherapy within 48 hours of symptom onset of mild-moderate ischaemic stroke.Methods/DesignThe study is a randomised, open-label, multicentre, prospective trial with a target enrolment of 2700 patients from 60 centres in Northeast China. A treatment allocation identification number to each enrolled patient will be provided by a random number generator. The follow-up time for the clopidogrel plus aspirin and aspirin monotherapy groups is 90 days. The primary efficacy endpoint is a stroke progression event, which is defined as ≥4 point increase in the NIHSS score in 48 hours. The second efficacy endpoints include new ischaemic stroke within 90 days, change in the NIHSS score within 14 days, modified Rankin Scale score on day 90 and other vascular or death events within 90 days. The safety endpoints include mucocutaneous haemorrhage, organ haemorrhage and intracranial haemorrhage, adverse events and severe adverse events. χ2 test, t-test (or Mann-Whitney test), survival analysis and Cox proportional hazards models will be conducted. The findings of the study may provide an important evidence for clinical practice for these patients.DiscussionThe trial will be conducted under a rational design and will provide valuable evidence on the appropriate treatment for this population.Ethics and disseminationThe study was reviewed and approved by the Ethics Committee of the General Hospital of Shen-Yang Military Region (no K(2016) 6).Trial registration numberNCT02869009; Pre-results.

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