scholarly journals Pharmacoeconomic evaluation of dual antiplatelet therapy in acute minor ischemic stroke

2019 ◽  
Vol 0 (1 (57)) ◽  
pp. 52-59
Author(s):  
O. R. Levytska ◽  
B. P. Hromovyk
Keyword(s):  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Pharmacoeconomic Evaluation ◽  
Minor Ischemic Stroke

Dual Antiplatelet Therapy after Intravenous Thrombolysis for Acute Minor Ischemic Stroke

2019 ◽  
Vol 82 (4-6) ◽  
pp. 93-98 ◽  
Author(s):  
Guangjian Zhao ◽  
Fanzhen Lin ◽  
Ziran Wang ◽  
Xiaolin Shao ◽  
Yanxue Gong ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Intravenous Thrombolysis ◽  
Recombinant Tissue Plasminogen Activator ◽  
Stroke Recurrence ◽  
Minor Ischemic Stroke ◽  
Significant Difference ◽  
Scale Scores ◽  
Symptomatic Intracranial Hemorrhage

Objective: To verify the efficacy and safety of dual antiplatelet therapy after intravenous thrombolysis for acute minor ischemic stroke (AMIS). Methods: AMIS patients who received recombinant tissue plasminogen activator (rt-PA) intravenous thrombolysis from January to October 2018 were retrospectively analyzed and divided into the aspirin (ASP) and ASP + clopidogrel (ASP-CLO) groups based on the type of antiplatelet therapy to compare the rates of good clinical outcome, symptomatic intracranial hemorrhage (SICH) after thrombolysis, and mortality in 90 days. Results: A total of 207 patients were included (group ASP, 105 patients; group ASP-CLO, 102 patients). There was no significant difference in the baseline clinical data between the 2 groups. The ­90-day modified Rankin scale scores (66.7 vs. 82.4%, p = 0.009) showed a statistically significant difference, but SICH (1.0 vs. 1.0%, p = 0.917) and 90-day mortality (1.9 vs. 1.0%, p = 0.585) showed no significant difference between the 2 groups. Conclusions: Short-term (21 days) dual antiplatelet therapy after rt-PA intravenous thrombolysis for AMIS can improve the prognosis, reduce the risk of stroke recurrence, without increasing the risk of bleeding and mortality.

scholarly journals Dual-Antiplatelet Therapy May Not Be Associated With an Increased Risk of In-hospital Bleeding in Patients With Moderate or Severe Ischemic Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Ossama Khazaal ◽  
Aaron Rothstein ◽  
Muhammad R. Husain ◽  
Matthew Broderick ◽  
Daniel Cristancho ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Major Bleeding ◽  
Primary Outcome ◽  
Dual Antiplatelet Therapy ◽  
Stroke Severity ◽  
Severe Stroke ◽  
Minor Ischemic Stroke ◽  
Increased Risk ◽  
Symptomatic Intracranial Hemorrhage

Background and Purpose: Dual antiplatelet therapy (DAPT), compared to single antiplatelet therapy (SAPT), lowers the risk of stroke or death early after TIA and minor ischemic stroke. Prior trials excluded moderate to severe strokes, due to a potential increased risk of bleeding. We aimed to compare in-hospital bleeding rates in SAPT and DAPT patients with moderate or severe stroke (defined by NIHSS ≥4).Methods: We performed a retrospective cohort study of ischemic stroke over a 2-year period with admission NIHSS ≥4. The primary outcome was symptomatic intracranial hemorrhage (ICH) with any change in NIHSS. Secondary outcomes included systemic bleeding and major bleeding, a composite of serious systemic bleeding and symptomatic ICH. We performed analyses stratified by stroke severity (NIHSS 4–7 vs. 8+) and by preceding use of tPA and/or thrombectomy. Univariate followed by multivariate logistic regression evaluated whether DAPT was independently associated with bleeding.Results: Of 377 patients who met our inclusion criteria, 148 received DAPT (39%). Symptomatic ICH was less common with DAPT compared to SAPT (0.7 vs. 6.4%, p < 0.01), as was the composite of major bleeding (2.1 vs. 7.6%, p = 0.03). Symptomatic ICH was numerically less frequent in the DAPT group, but not statistically significant, when stratified by stroke severity (NIHSS 4–7: 0 vs. 5.9%, p = 0.06; NIHSS 8+: 1.5 vs. 6.6%, p = 0.18) and by treatment with tPA and/or thrombectomy (Yes: 2.6 vs. 9.1%, p = 0.30; No: 0 vs. 2.9%, p = 0.25). DAPT was not associated with major bleeding in either the univariate or the multivariate regression.Conclusions: In this single center cohort, symptomatic ICH and the composite of serious systemic bleeding and symptomatic ICH was rare in patients on DAPT. Relative to single antiplatelet therapy DAPT was not associated with an increased risk of in-hospital bleeding in patients with moderate and severe ischemic stroke.

Clinical Effects of Dual Antiplatelet Therapy or Aspirin Monotherapy after Acute Minor Ischemic Stroke or Transient Ischemic Attack, a Meta-Analysis

2021 ◽  
Vol 27 ◽  
Author(s):  
Francesco Condello ◽  
Gaetano Liccardo ◽  
Giuseppe Ferrante
Keyword(s):  
Ischemic Stroke ◽  
Major Bleeding ◽  
Transient Ischemic Attack ◽  
Hemorrhagic Stroke ◽  
Dual Antiplatelet Therapy ◽  
Meta Analysis ◽  
Stroke Recurrence ◽  
Controlled Trials ◽  
Minor Ischemic Stroke ◽  
Ischemic Attack

Background: Evidence about the use of dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitors in patients with acute minor ischemic stroke or transient ischemic attack (TIA) is emerging. The aim of our study was to provide an updated and comprehensive analysis about the risks and benefits of DAPT versus aspirin monotherapy in this setting. Methods: The PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov databases, main international conference proceedings were searched for randomized controlled trials comparing DAPT versus aspirin monotherapy in patients with acute ischemic stroke or TIA not eligible for thrombolysis or thrombectomy presenting in the first 24 hours after the acute event. Data were pooled by meta-analysis using a random-effects model. The primary efficacy endpoint was ischemic stroke recurrence, and the primary safety outcome was major bleeding. Secondary endpoints were intracranial hemorrhage, hemorrhagic stroke, and all-cause death. Results: A total of 4 studies enrolling 21,459 patients were included. DAPT with clopidogrel was used in 3 studies, DAPT with ticagrelor in one study. DAPT duration was 21 days in one study, 1 month in one study, and 3 months in the remaining studies. DAPT was associated with a significant reduction in the risk of ischemic stroke recurrence (relative risk [RR], 0.74; 95% confidence interval [CI], 0.67-0.82, P<0.001, number needed to treat 50 [95% CI 40-72], while it was associated with a significantly higher risk of major bleeding (RR, 2.59; 95% CI 1.49-4.53, P=0.001, number needed to harm 330 [95% CI 149-1111]), of intracranial hemorrhage (RR 3.06, 95% CI 1.41-6.66, P=0.005), with a trend towards higher risk of hemorrhagic stroke (RR 1.83, 95% CI 0.83-4.05, P=0.14), and a slight tendency towards higher risk of all-cause death (RR 1.30, 95% CI 0.89-1.89, P=0.16). Conclusions: Among patients with acute minor ischemic stroke or TIA, DAPT, as compared with aspirin monotherapy, might offer better effectiveness in terms of ischemic stroke recurrence at the expense of a higher risk of major bleeding. The trade-off between ischemic benefits and bleeding risks should be assessed in tailoring the therapeutic strategies.

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.

scholarly journals Ticagrelor and Acetylsalicylic Acid after Placement of Pipeline Embolization Device for Cerebral Aneurysm: A Case Series

2019 ◽  
Vol 71 (6) ◽  
Author(s):  
Jodi R DeGrote ◽  
Elizabeth M Olafson ◽  
Alexander Drofa ◽  
Evgueni Kouznetzov ◽  
Michael Manchak ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acetylsalicylic Acid ◽  
Cerebral Aneurysm ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Case Series ◽  
Bleeding Complications ◽  
Attractive Alternative ◽  
Pipeline Embolization Device ◽  
End Point

<p><strong>ABSTRACT</strong><br /><strong></strong></p><p><strong>Background:</strong> Dual antiplatelet therapy with acetylsalicylic acid (ASA) and a P2Y12-receptor antagonist is often used to prevent thrombotic complications after placement of a Pipeline embolization device (PED) for cerebral aneurysm. Although clopidogrel is common in this setting, high rates of nonresponse to this drug have made ticagrelor a potentially attractive alternative. <br /><strong></strong></p><p><strong>Objective:</strong> To describe safety and efficacy outcomes for ticagrelor following PED placement, including measurement of platelet function.<br /><strong></strong></p><p><strong>Methods:</strong> A retrospective analysis of data was completed for patients who underwent PED placement for cerebral aneurysm at a single centre between November 2015 and March 2017, with subsequent prescription of ticagrelor and ASA as dual antiplatelet therapy. The primary end point was any ischemic stroke or death within 1 year after the procedure. Intracranial hemorrhage was a secondary end point. Additionally, measurement of and values for platelet reactivity units (PRUs) during receipt of ticagrelor and ASA were evaluated.<br /><strong></strong></p><p><strong>Results:</strong> A total of 29 patients were included in this retrospective study. One patient experienced ischemic stroke 226 days after placement of the PED. In addition, 3 patients died during the 1-year follow-up period for causes unrelated to stroke or bleeding complications. No cases of intra -cranial hemorrhage were observed. Samples for measurement of P2Y12 levels were drawn at the discretion of the neurointerventionalists, and the PRU value was measured at least once for 28 (97%) of the 29 patients. The mean number of PRU measurements per patient after initiation of ticagrelor was 2.1 (standard deviation [SD] 1). Mean PRU value after initiation of ticagrelor was 65 (SD 57). <br /><strong></strong></p><p><strong>Conclusions:</strong> In this case series describing the use of ticagrelor and ASA as dual antiplatelet therapy after PED placement for cerebral aneurysm, there was just one ischemic stroke, which occurred after the dual antiplatelet therapy had been discontinued. Further prospective trials are needed to describe the utility of ticagrelor use after PED placement, as well as its dosing and monitoring.</p><p><strong>RÉSUMÉ</strong></p><p><strong></strong><strong>Contexte :</strong> Une bithérapie antiplaquettaire composée d’acide acétylsali-cylique (AAS) et d’un inhibiteur du récepteur P2Y12 est fréquemment utilisée pour prévenir les complications thrombotiques après la mise en place d’un dispositif d’embolisation Pipeline pour traiter un anévrisme cérébral. Quoique le clopidogrel soit souvent utilisé dans ce contexte, des taux élevés d’absence de réponse à ce médicament ont fait du ticagrélor une solution de rechange potentiellement intéressante. <br /><strong></strong></p><p><strong>Objectif :</strong> Décrire les résultats relatifs à la sécurité et à l’efficacité du ticagrélor après la mise en place d’un dispositif d’embolisation, y compris l’analyse de la fonction plaquettaire.<br /><strong></strong></p><p><strong>Méthodes :</strong> Une analyse rétrospective de données a été réalisée dans un seul centre entre novembre 2015 et mars 2017 à l’aide des dossiers médicaux de patients chez qui a été posé un dispositif d’embolisation Pipeline comme traitement pour un anévrisme cérébral et à qui a ensuite été prescrite une bithérapie antiplaquettaire de ticagrélor et d’AAS. Le critère d’évaluation principal était les cas d’infarctus cérébral ou de décès durant l’année suivant l’opération. Les cas d’hémorragie intracrânienne ont servi de critère d’évaluation secondaire. De plus, l’analyse a porté sur l’évaluation de la réactivité plaquettaire et sa quantification en unités de réaction au P2Y12 pendant la prise de ticagrélor et d’AAS.<br /><strong></strong></p><p><strong>Résultats :</strong> Au total, 29 patients ont été admis à la présente étude rétrospective. Un patient a subi un infarctus cérébral 226 jours après la mise en place d’un dispositif d’embolisation Pipeline. De plus, 3 patients sont décédés au cours de la période de suivi d’un an en raison de causes sans lien avec des complications liées à un accident vasculaire cérébral ou à une hémorragie. Aucun cas d’hémorragie intracrânienne n’a été observé. Les échantillons destinés à la mesure des unités de réaction au P2Y12 ont été prélevés selon le jugement des neuro-intervenants et l’évaluation de la réactivité plaquettaire a été réalisée au moins une fois chez 28 (97 %) des 29 patients. Le nombre moyen de mesures des unités de réaction au P2Y12 par patient était de 2,1 (écart-type de 1). Après l’amorce d’un traitement par ticagrélor, le résultat moyen en unités de réaction au P2Y12 était de 65 (écart-type de 57).</p><p><strong>Conclusions :</strong> Dans la présente série de cas décrivant l’utilisation d’une bithérapie antiplaquettaire composée de ticagrélor et d’AAS après la mise en place d’un dispositif d’embolisation Pipeline comme traitement pour un anévrisme cérébral, seul un cas d’infarctus cérébral a été observé et il s’est produit après l’arrêt de la bithérapie antiplaquettaire. De plus amples études prospectives sont nécessaires pour décrire l’utilité et la posologie du ticagrélor ainsi que le suivi du traitement après la mise en place d’un dis-positif d’embolisation Pipeline.</p>

Indications and Evidence for Dual Antiplatelet Therapy After Acute Ischemic Stroke

2020 ◽  
Vol 43 (2) ◽  
pp. 122-137
Author(s):  
Jessica Ringler ◽  
Mackenzie Steck ◽  
Samarth P. Shah ◽  
Katleen W. Chester
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy
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