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Gao Y, Jiang L, Pan Y, Chen W, Jing J, Wang C, Johnston SC, Amarenco P, Bath PM, Yang Y, Wang T, Han S, Meng X, Lin J, Zhao X, Liu L, Zhao J, Li Y, Zang Y, Zhang S, Yang H, Yang J, Wang Y, Li D, Wang Y, Liu D, Kang G, Wang Y, Wang Y. Immediate- or Delayed-Intensive Statin in Acute Cerebral Ischemia: The INSPIRES Randomized Clinical Trial. JAMA Neurol 2024:2819378. [PMID: 38805216 DOI: 10.1001/jamaneurol.2024.1433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Importance Comparisons are limited for immediate-intensive and delayed-intensive statin for secondary stroke prevention and neuroprotection in patients with acute mild ischemic stroke or transient ischemic attack (TIA) from atherosclerosis. Objective To estimate whether immediate-intensive statin therapy is safe and can lower the risk of recurrent stroke compared with delayed-intensive statin in patients with acute mild ischemic stroke or high-risk TIA from atherosclerosis. Design, Setting, and Participants The Intensive Statin and Antiplatelet Therapy for High-Risk Intracranial or Extracranial Atherosclerosis (INSPIRES) trial, a double-blind, placebo-controlled, 2 × 2 factorial, randomized clinical trial enrolled patients from September 2018 to October 2022. The trial was conducted at 222 hospitals in China. Patients aged 35 to 80 years with mild ischemic stroke or high-risk TIA of presumed atherosclerosis within 72 hours of symptom onset were assessed. Interventions Patients were randomly assigned to receive immediate-intensive atorvastatin (80 mg daily on days 1-21; 40 mg daily on days 22-90) or 3-day delayed treatment (placebo for days 1-3, followed by placebo and atorvastatin, 40 mg daily on days 4-21, and then atorvastatin, 40 mg daily on days 22-90). Main Outcomes and Measures The primary efficacy outcome was new stroke within 90 days, and a secondary efficacy outcome was poor functional outcome. Moderate to severe bleeding was the primary safety outcome. Results A total of 11 431 patients were assessed for eligibility, and 6100 patients (median [IQR] age, 65 [57-71] years; 3915 men [64.2%]) were enrolled, with 3050 assigned to each treatment group. Within 90 days, new stroke occurred in 245 patients (8.1%) in the immediate-intensive statin group and 256 patients (8.4%) in the delayed group (hazard ratio, 0.95; 95% CI, 0.80-1.13). Poor functional outcome occurred in 299 patients (9.8%) and 348 patients (11.4%) in the immediate-intensive and delayed-intensive statin groups, respectively (odds ratio, 0.83; 95% CI, 0.71-0.98). Moderate to severe bleeding occurred in 23 of 3050 patients (0.8%) and 17 of 3050 patients (0.6%), in the immediate-intensive and delayed-intensive statin groups, respectively. Conclusions and Relevance Immediate-intensive statin initiated within 72 hours did not reduce the risk of stroke within 90 days and may be associated with improved functional outcomes without significant difference in moderate to severe bleeding, compared with 3-day delayed-intensive statin in Chinese patients with acute mild ischemic stroke or TIA from atherosclerosis. Trial Registration ClinicalTrials.gov Identifier: NCT03635749.
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Affiliation(s)
- Ying Gao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lingling Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Pierre Amarenco
- Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM LVTS-U1148, University of Paris, Paris, France
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Yingying Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shangrong Han
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinguo Zhao
- Department of Neurology, Weihai Wendeng District People's Hospital, Weihai, China
| | - Ying Li
- Department of Neurology, Sui Chinese Medical Hospital, Shangqiu, China
| | - Yingzhuo Zang
- Department of Neurology, Qinghe People's Hospital, Xingtai, China
| | - Shuo Zhang
- Department of Neurology, Biyang People's Hospital, Zhumadian, China
| | - Hongqin Yang
- Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan, China
| | - Jianbo Yang
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yuanwei Wang
- Department of Neurology, The Affiliated Shuyang Hospital of Xuzhou Medical University, Shuyang Hospital, Suqian, China
| | - Dali Li
- Department of Neurology, Mengzhou People's Hospital, Jiaozuo, China
| | - Yanxia Wang
- Department of Neurology, Hejian People's Hospital, Cangzhou, China
| | - Dongqi Liu
- Department of Neurology, Hejian People's Hospital, Cangzhou, China
| | - Guangming Kang
- Department of Neurology, Xiuwu People's Hospital, Jiaozuo, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- National Center for Neurological Disorders, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
- Beijing Laboratory of Oral Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing, China
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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Blair G, Appleton JP, Mhlanga I, Woodhouse LJ, Doubal F, Bath PM, Wardlaw JM. Design of trials in lacunar stroke and cerebral small vessel disease: review and experience with the LACunar Intervention Trial 2 (LACI-2). Stroke Vasc Neurol 2024:svn-2023-003022. [PMID: 38569894 DOI: 10.1136/svn-2023-003022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/02/2024] [Indexed: 04/05/2024] Open
Abstract
Cerebral small vessel disease (cSVD) causes lacunar stroke (25% of ischaemic strokes), haemorrhage, dementia, physical frailty, or is 'covert', but has no specific treatment. Uncertainties about the design of clinical trials in cSVD, which patients to include or outcomes to assess, may have delayed progress. Based on experience in recent cSVD trials, we reviewed ways to facilitate future trials in patients with cSVD.We assessed the literature and the LACunar Intervention Trial 2 (LACI-2) for data to inform choice of Participant, Intervention, Comparator, Outcome, including clinical versus intermediary endpoints, potential interventions, effect of outcome on missing data, methods to aid retention and reduce data loss. We modelled risk of missing outcomes by baseline prognostic variables in LACI-2 using binary logistic regression.Imaging versus clinical outcomes led to larger proportions of missing data. We present reasons for and against broad versus narrow entry criteria. We identified numerous repurposable drugs with relevant modes of action to test in various cSVD subtypes. Cognitive impairment is the most common clinical outcome after lacunar ischaemic stroke but was missing more frequently than dependency, quality of life or vascular events in LACI-2. Assessing cognitive status using Diagnostic and Statistical Manual for Mental Disorders Fifth Edition can use cognitive data from multiple sources and may help reduce data losses.Trials in patients with all cSVD subtypes are urgently needed and should use broad entry criteria and clinical outcomes and focus on ways to maximise collection of cognitive outcomes to avoid missing data.
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Affiliation(s)
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Wardlaw JM, Chabriat H, de Leeuw FE, Debette S, Dichgans M, Doubal F, Jokinen H, Katsanos AH, Ornello R, Pantoni L, Pasi M, Pavlovic AM, Rudilosso S, Schmidt R, Staals J, Taylor-Rowan M, Hussain S, Lindgren AG. European stroke organisation (ESO) guideline on cerebral small vessel disease, part 2, lacunar ischaemic stroke. Eur Stroke J 2024; 9:5-68. [PMID: 38380638 PMCID: PMC10916806 DOI: 10.1177/23969873231219416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 11/22/2023] [Indexed: 02/22/2024] Open
Abstract
A quarter of ischaemic strokes are lacunar subtype, typically neurologically mild, usually resulting from intrinsic cerebral small vessel pathology, with risk factor profiles and outcome rates differing from other stroke subtypes. This European Stroke Organisation (ESO) guideline provides evidence-based recommendations to assist with clinical decisions about management of lacunar ischaemic stroke to prevent adverse clinical outcomes. The guideline was developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We addressed acute treatment (including progressive lacunar stroke) and secondary prevention in lacunar ischaemic stroke, and prioritised the interventions of thrombolysis, antiplatelet drugs, blood pressure lowering, lipid lowering, lifestyle, and other interventions and their potential effects on the clinical outcomes recurrent stroke, dependency, major adverse cardiovascular events, death, cognitive decline, mobility, gait, or mood disorders. We systematically reviewed the literature, assessed the evidence and where feasible formulated evidence-based recommendations, and expert concensus statements. We found little direct evidence, mostly of low quality. We recommend that patients with suspected acute lacunar ischaemic stroke receive intravenous alteplase, antiplatelet drugs and avoid blood pressure lowering according to current acute ischaemic stroke guidelines. For secondary prevention, we recommend single antiplatelet treatment long-term, blood pressure control, and lipid lowering according to current guidelines. We recommend smoking cessation, regular exercise, other healthy lifestyle modifications, and avoid obesity for general health benefits. We cannot make any recommendation concerning progressive stroke or other drugs. Large randomised controlled trials with clinically important endpoints, including cognitive endpoints, are a priority for lacunar ischaemic stroke.
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Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Hugues Chabriat
- CNVT and Department of Neurology, Hopital Lariboisière, Paris, France
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Stéphanie Debette
- Bordeaux Population Health Research Center; University of Bordeaux – Inserm U1219; Bordeaux; Department of Neurology, Institute for Neurodegenerative Diseases, Bordeaux University Hospital, Bordeaux, France
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Medical Center, Munich; Munich Cluster for Systems Neurology (SyNergy), Munich; German Center for Neurodegenerative Diseases (DZNE, Munich), Munich; German Centre for Cardiovascular Research (DZHK, Munich), Munich, Germany
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor’s Building, Edinburgh, UK
| | - Hanna Jokinen
- Neurocenter, Helsinki University Hospital and University of Helsinki, HUS, Helsinki, Finland
| | - Aristeidis H Katsanos
- Neurology, McMaster University & Population Health Research Institute, Hamilton, ON, Canada
| | - Raffaele Ornello
- Neurology/Department of Biotechnological ad Applied Clinical Sciences, University of L’Aquila, L’Aquila, Italy
| | | | - Marco Pasi
- Department of Neurology, University of Tours, Tours, France
| | - Aleksandra M Pavlovic
- University of Belgrade, Faculty of Special Education and Rehabilitation, Belgrade, Serbia
| | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neurology, Hospital Clínic of Barcelona, Barcelona, Spain
| | | | - Julie Staals
- Department of Neurology and CARIM School for cardiovascular diseases, MUMC+, Maastricht, The Netherlands
| | - Martin Taylor-Rowan
- School of Health and Wellbeing; General Practice and Primary Care, Clarice Pears Building, University of Glasgow, Glasgow, UK
| | | | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University; Department of Neurology, Skåne University Hospital, Lund, Skånes Universitetssjukhus, Lund, Sweden
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5
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Meng X, Wang A, Tian X, Johnston C, Li H, Bath PM, Xu Q, Zhang Y, Xie X, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Wang Y. One-Year Outcomes of Early Therapy With Ticagrelor vs Clopidogrel in CYP2C19 Loss-of-Function Carriers With Stroke or TIA Trial. Neurology 2024; 102:e207809. [PMID: 38181311 DOI: 10.1212/wnl.0000000000207809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 11/07/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial showed that among Chinese patients with minor ischemic stroke or transient ischemic attack (TIA) who were carriers of CYP2C19 loss-of-function alleles, dual-antiplatelet therapy with ticagrelor-aspirin reduced the 90-day risk of stroke without increased severe or moderate bleeding compared with clopidogrel-aspirin. However, whether dual-antiplatelet therapy with ticagrelor was superior to clopidogrel beyond the 90 days of follow-up remained unclear. In this study, we reported 1-year follow-up outcomes of the CHANCE-2 trial. METHODS The CHANCE-2 trial is a randomized, double-blind, placebo-controlled trial at 202 centers in China. Patients with a minor stroke or TIA who carried CYP2C19 loss-of-function alleles were randomized within 24 hours after symptom onset, in a 1:1 ratio, to receive ticagrelor and placebo clopidogrel or to receive clopidogrel and placebo ticagrelor for 90 days; both groups received aspirin for the first 21 days. After day 90, treatment was as per the choice of the clinician and the patient. RESULTS Among 6,412 patients, the proportion of patients on ticagrelor plus aspirin, clopidogrel plus aspirin, ticagrelor alone, clopidogrel alone, aspirin alone, other antiplatelet, and no antiplatelet beyond month 3 to 1 year was 0.09%, 1.56%, 0.13%, 2.66%, 73.65%, 0.78%, and 21.13% in the ticagrelor-aspirin group and 0.03%, 1.63%, 0.19%, 2.60%, 72.83%, 0.66%, and 22.06% in the clopidogrel-aspirin group, respectively. The primary outcome of new stroke occurred in 252 patients (7.91%) in the ticagrelor-aspirin group and 310 patients (9.73%) in the clopidogrel-aspirin group by 1 year of follow-up (hazard ratio 0.80; 95% CI 0.68-0.95; p = 0.007); new stroke beyond 3 months to 1 year occurred in 61 patients (2.07%) and 67 patients (2.32%) (p = 0.48), respectively. Primary safety outcome of severe or moderate bleeding occurred in 17 patients (0.53%) in the ticagrelor-aspirin group and 20 patients (0.63%) in the clopidogrel-aspirin group (p = 0.61). DISCUSSION For CYP2C19 loss-of-function allele carriers, early dual-antiplatelet therapy with ticagrelor is superior to clopidogrel at 1 year in reducing recurrent stroke. TRIAL REGISTRATION INFORMATION URL: clinicaltrials.gov. Unique identifier: NCT04078737. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with minor stroke or TIA with TIACYP2C19 loss-of-function, ticagrelor plus aspirin for 21 days is superior to clopidogrel plus aspirin in reducing the 1-year risk of recurrent stroke.
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Affiliation(s)
- Xia Meng
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Anxin Wang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Xue Tian
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Claiborne Johnston
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Hao Li
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Philip M Bath
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Qin Xu
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Yijun Zhang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Xuewei Xie
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Jing Jing
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Jinxi Lin
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Yilong Wang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Xingquan Zhao
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Zixiao Li
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Yong Jiang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Liping Liu
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
| | - Yongjun Wang
- From the Department of Neurology (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.) and Advanced Innovation Center for Human Brain Protection (Yo.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (X.M., A.W., X.T., H.L., Y.Z., X.X., J.J., J.L., Yi.W., X.Z., Z.L., L.L., Y.J., Yo.W.), Beijing; Department of Epidemiology and Health Statistics (X.T., Y.Z.), School of Public Health, Capital Medical University, Beijing; Beijing Municipal Key Laboratory of Clinical Epidemiology (X.T.,Y.Z.), China; Department of Neurology (S.C.J.), University of California, San Francisco; and Stroke Trials Unit (P.M.B.), Mental Health & Clinical Neuroscience, University of Nottingham, UK
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6
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Wang A, Tian X, Xie X, Li H, Bath PM, Jing J, Lin J, Wang Y, Zhao X, Li Z, Liu L, Wang Y, Meng X. Differential effect of ticagrelor versus clopidogrel by homocysteine levels on risk of recurrent stroke: a post hoc analysis of the CHANCE-2 trial. CMAJ 2024; 196:E149-E156. [PMID: 38346785 PMCID: PMC10861269 DOI: 10.1503/cmaj.231262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Elevated homocysteine levels are associated with increased blood coagulation and platelet activity and may modulate the response to antiplatelet therapies. We aimed to investigate the effects of homocysteine levels on the efficacy and safety of ticagrelor-acetylsalicylic acid (ASA) versus clopidogrel-ASA among patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles. METHODS We conducted a post hoc analysis of the CHANCE-2 (The Clopidogrel in High-risk Patients with Acute Nondisabling Cerebrovascular Events-II) trial. Participants were randomly assigned to treatment with ticagrelor-ASA or clopidogrel-ASA. We categorized participants into groups with elevated and non-elevated homocysteine levels, based on the median level. The primary efficacy outcome was recurrent stroke within 90-day follow-up. The primary safety outcome was severe or moderate bleeding within 90 days. RESULTS A total of 2740 participants were randomly assigned to receive ticagrelor-ASA and 2700 to receive clopidogrel-ASA. Use of ticagrelor-ASA was associated with a reduced risk of recurrent stroke among participants with elevated homocysteine levels (74 [5.3%] v. 119 [8.5%]; hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.45-0.81), but not among those with non-elevated levels (86 [6.4%] v. 87 [6.7%]; HR 0.97, 95% CI 0.71-1.32; p = 0.04 for interaction). When analyzed as a continuous variable, the benefits of ticagrelor-ASA with regard to recurrent stroke increased as homocysteine levels increased (p = 0.04 for interaction). No significant interaction between homocysteine levels and treatment with regard to severe or moderate bleeding was observed (p = 0.7 for interaction). We found a significant interaction between homocysteine levels and therapy with regard to recurrent stroke in females (p = 0.04 for interaction) but not males. INTERPRETATION In comparison with clopidogrel-ASA, ticagrelor-ASA conferred more benefit to patients with elevated homocysteine levels, particularly to female patients, in this secondary analysis of a randomized controlled trial involving patients with minor ischemic stroke or TIA. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT04078737.
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Affiliation(s)
- Anxin Wang
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xue Tian
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuewei Xie
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Philip M Bath
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxi Lin
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Kappel AD, Nguyen HB, Frerichs KU, Patel NJ, Aziz-Sultan MA, Du R. Randomized Clinical Trials in Cerebrovascular Neurosurgery From 2018 to 2022. Cureus 2024; 16:e52397. [PMID: 38361699 PMCID: PMC10869144 DOI: 10.7759/cureus.52397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
There has been an exponential increase in randomized controlled trials (RCTs) on cerebrovascular disease within neurosurgery. The goal of this study was to review, outline the scope, and summarize all phase 2b and phase 3 RCTs impacting cerebrovascular neurosurgery practice since 2018. We searched PubMed, MEDLINE, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases for relevant RCTs published between January 1, 2018, and July 1, 2022. We searched for studies related to eight major cerebrovascular disorders relevant to neurosurgery, including acute ischemic stroke, cerebral aneurysms and subarachnoid hemorrhage, intracerebral hemorrhage, subdural hematomas, cerebral venous thrombosis, arteriovenous malformations, Moyamoya disease and extracranial-intracranial bypass, and carotid and intracranial atherosclerosis. We limited our search to phase 2b or 3 RCTs related to cerebrovascular disorders published during the study period. The titles and abstracts of all relevant studies meeting our search criteria were included. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. From an initial total of 2,797 records retrieved from the database searches, 1,641 records were screened after duplicates and studies outside of our time period were removed. After screening, 511 available reports within our time period of interest were assessed for eligibility. Pediatric studies, stroke studies related to rehabilitation or cardiovascular disease, study protocols without published results, prospective cohort studies, registry studies, cluster randomized trials, and nonrandomized pivotal trials were excluded. We found 80 unique phase 2b or 3 RCTs that fit our criteria, with 165 topic-relevant articles published within the study period. Numerous RCTs in cerebrovascular neurosurgery have been published since 2018. Ischemic stroke, including mechanical thrombectomy and thrombolysis, accounted for a majority of publications, but there were large trials in intracerebral hemorrhage, subdural hemorrhage, aneurysms, subarachnoid hemorrhage, and cerebral venous thrombosis, among others. This review helps define the scope of the large RCTs published in the last four years to guide future research and clinical care.
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Affiliation(s)
- Ari D Kappel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | | | - Nirav J Patel
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
| | | | - Rose Du
- Neurosurgery, Brigham and Women's Hospital, Boston, USA
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Gao Y, Chen W, Pan Y, Jing J, Wang C, Johnston SC, Amarenco P, Bath PM, Jiang L, Yang Y, Wang T, Han S, Meng X, Lin J, Zhao X, Liu L, Zhao J, Li Y, Zang Y, Zhang S, Yang H, Yang J, Wang Y, Li D, Wang Y, Liu D, Kang G, Wang Y, Wang Y. Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke. N Engl J Med 2023; 389:2413-2424. [PMID: 38157499 DOI: 10.1056/nejmoa2309137] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Dual antiplatelet treatment has been shown to lower the risk of recurrent stroke as compared with aspirin alone when treatment is initiated early (≤24 hours) after an acute mild stroke. The effect of clopidogrel plus aspirin as compared with aspirin alone administered within 72 hours after the onset of acute cerebral ischemia from atherosclerosis has not been well studied. METHODS In 222 hospitals in China, we conducted a double-blind, randomized, placebo-controlled, two-by-two factorial trial involving patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) of presumed atherosclerotic cause who had not undergone thrombolysis or thrombectomy. Patients were randomly assigned, in a 1:1 ratio, within 72 hours after symptom onset to receive clopidogrel (300 mg on day 1 and 75 mg daily on days 2 to 90) plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 21) or matching clopidogrel placebo plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 90). There was no interaction between this component of the factorial trial design and a second part that compared immediate with delayed statin treatment (not reported here). The primary efficacy outcome was new stroke, and the primary safety outcome was moderate-to-severe bleeding - both assessed within 90 days. RESULTS A total of 6100 patients were enrolled, with 3050 assigned to each trial group. TIA was the qualifying event for enrollment in 13.1% of the patients. A total of 12.8% of the patients were assigned to a treatment group no more than 24 hours after stroke onset, and 87.2% were assigned after 24 hours and no more than 72 hours after stroke onset. A new stroke occurred in 222 patients (7.3%) in the clopidogrel-aspirin group and in 279 (9.2%) in the aspirin group (hazard ratio, 0.79; 95% confidence interval [CI], 0.66 to 0.94; P = 0.008). Moderate-to-severe bleeding occurred in 27 patients (0.9%) in the clopidogrel-aspirin group and in 13 (0.4%) in the aspirin group (hazard ratio, 2.08; 95% CI, 1.07 to 4.04; P = 0.03). CONCLUSIONS Among patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, combined clopidogrel-aspirin therapy initiated within 72 hours after stroke onset led to a lower risk of new stroke at 90 days than aspirin therapy alone but was associated with a low but higher risk of moderate-to-severe bleeding. (Funded by the National Natural Science Foundation of China and others; INSPIRES ClinicalTrials.gov number, NCT03635749.).
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Affiliation(s)
- Ying Gao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Weiqi Chen
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jing Jing
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Chunjuan Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - S Claiborne Johnston
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Pierre Amarenco
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Philip M Bath
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Lingling Jiang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingying Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Tingting Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Shangrong Han
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinxi Lin
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xingquan Zhao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Liping Liu
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinguo Zhao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Ying Li
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingzhuo Zang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Shuo Zhang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Hongqin Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jianbo Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuanwei Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Dali Li
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yanxia Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Dongqi Liu
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Guangming Kang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
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9
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Han X, Li Y, Chen X, Pan D, Mo J, Qiu J, Li Y, Chen Y, Huang Y, Shen Q, Tang Y. Platelet-activating factor antagonist-based intensive antiplatelet strategy in acute ischemic stroke: A propensity score matched with network pharmacology analysis. CNS Neurosci Ther 2023; 29:4082-4092. [PMID: 37435773 PMCID: PMC10651968 DOI: 10.1111/cns.14331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/25/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND Diterpene ginkgolides meglumine injection (DGMI) is a platelet-activating factor receptor (PAFR) antagonist that can be used to treat acute ischemic stroke (AIS). This study evaluated the efficacy and safety of an intensive antiplatelet strategy based on PAFR antagonists and explored the underlying mechanisms of PAFR antagonists in AIS treatment. METHODS This is a retrospective study applying propensity score methods to match AIS patients treated with DGMI to nontreated patients. The primary outcome was functional independence (modified Rankin Scale [mRS] 0-2) at 90 days. The safety outcome was bleeding risk. We used McNemar test to compare the efficacy outcome. Subsequently, the network pharmacology analysis was performed. RESULTS 161 AIS patients treated with DGMI in the study were matched with 161 untreated patients. Compared with untreated patients, DGMI-treated patients had a significantly higher rate of mRS ranking 0-2 at 90 days (82.0% vs. 75.8%, p < 0.001), without increased risk of bleeding. The gene enrichment analysis showed that the overlap genes of DGMI targeted and AIS-related enriched in thrombosis and inflammatory-related signaling pathways. CONCLUSIONS An intensive antiplatelet strategy of DGMI plus traditional antiplatelet agents is effective in treating AIS and may work by mediating post-stroke inflammation and thrombosis.
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Affiliation(s)
- Xiaoyan Han
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
| | - Youjia Li
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Xuemin Chen
- Guangdong Medical UniversityZhanjiangPeople's Republic of China
| | - Dong Pan
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
| | - Junning Mo
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Jiaming Qiu
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Yi Li
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
| | - Yan Chen
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Yan Huang
- Department of NeurologyFirst People's Hospital of ZhaoqingZhaoqingPeople's Republic of China
| | - Qingyu Shen
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
| | - Yamei Tang
- Department of Neurology, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat‐sen Memorial HospitalSun Yat‐sen UniversityGuangzhouPeople's Republic of China
- Guangdong Province Key Laboratory of Brain Function and Disease, Zhongshan School of MedicineSun Yat‐Sen UniversityGuangzhouPeople's Republic of China
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10
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Al-Shahi Salman R, Greenberg SM. Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage. Stroke 2023; 54:3173-3181. [PMID: 37916459 DOI: 10.1161/strokeaha.123.036886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75-0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97-2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients' predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25-1.03]; P=0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.
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Affiliation(s)
| | - Steven M Greenberg
- Massachusetts General Hospital and Harvard Medical School, Boston (S.M.G.)
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11
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Li Q, Xiao M, Liu X, Zhao Y, Zhang H, Yin Y, Qiu P, Lu F, Gao R. Enhancing open clinical trials through blinded evaluations: an exploration with diabetic foot infections. Trials 2023; 24:716. [PMID: 37946260 PMCID: PMC10636892 DOI: 10.1186/s13063-023-07652-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/14/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Blinding drugs through simulation techniques is an important means to control the subjective bias of investigators and subjects. However, clinical trials face significant challenges in the placebo production of drugs, and many trials cannot be double-blinded. OBJECTIVE This study was conducted to ascertain the consistency between non-blind and blind evaluation results in clinical trials and to pioneer strategies to control information bias, particularly in trials where double-blinding is not feasible. METHODS In this investigation, a randomized controlled trial (RCT) studying diabetic foot infections (DFIs) was utilized as a representative case. In this trial, the grading of DFIs, as per guidelines by the Infectious Disease Society of America (IDSA) and International Working Group on Diabetic Foot (IWGDF), was used as the primary efficacy indicator. A sample of sixteen patients was randomly chosen from the RCT, and DFI grading was assessed jointly by both non-blinded investigators and blinded center-reading investigators. A consistency test was then deployed to compare the evaluation results, forming the basis for our proposed strategies for effective blinded evaluation. In addition, other perspectives were collected at the end of this study, including with those involved in designing and conducting the recent blinded evaluation trial. RESULTS Five subjects were excluded due to the quality of photos or the lack of post-treatment visits. The post-treatment IDSA/IWGDF grading results were compared in 11 subjects (experimental group=6, control group=5), and the consistency test showed inconsistent results between the non-blinded and center reading blinded evaluations (Kappa=0.248, p=0.384). In the experimental group, three cases were judged as grade 1 in the non-blinded evaluation and grade 2 in the central reading blinded evaluation; in the control group, three cases were judged as grade 2 in the non-blinded evaluation and grade 1 in the central reading blinded evaluation. The sum of these two cases in 22 post-treatment determinations was 27% (6/22). Furthermore, researchers propose several strategies for implementing blinded evaluations in clinical trials after this trial, which encompass aspects such as staff allocation, training, participant management, trial drug administration, efficacy indicator collection, and safety event management. CONCLUSIONS The study highlighted that evaluations from non-blinded site investigators may potentially exaggerate the efficacy of the experimental group and that deep wounds can present challenges for observation via center-reading photos. These findings underline the vital necessity for objective assessment in open clinical trials, especially those where wound observation serves as the primary efficacy indicator. The study suggests the adoption of independent blinded investigators at each site, complemented by a comprehensive set of standard operating procedures for blinding evaluation. These measures could serve as an effective counterbalance to subjective bias, thereby augmenting the credibility and consistency of results in open clinical trials. The implications of these findings and recommendations could be of great significance for the design and execution of future open clinical trials, potentially bolstering the quality of clinical research in this area. TRIAL REGISTRATION ChiCTR2000041443. Registered on December 2020.
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Affiliation(s)
- Qingna Li
- Institution of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
- Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine of National Medical Products Administration, Beijing, China
| | - Mengli Xiao
- Institution of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
- Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine of National Medical Products Administration, Beijing, China
| | - Xingfang Liu
- Research Department, Swiss University of Traditional Chinese Medicine, Bad Zurzach, Switzerland
| | - Yang Zhao
- Institution of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
- Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine of National Medical Products Administration, Beijing, China
| | - Haoling Zhang
- Institution of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
- Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine of National Medical Products Administration, Beijing, China
| | - Yundong Yin
- Institution of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
- Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine of National Medical Products Administration, Beijing, China
| | - Panbo Qiu
- Institution of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China
- Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine of National Medical Products Administration, Beijing, China
| | - Fang Lu
- Institution of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China.
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China.
- Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine of National Medical Products Administration, Beijing, China.
| | - Rui Gao
- Institution of Clinical Pharmacology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing, China.
- National Clinical Research Center for Chinese Medicine Cardiology, Beijing, China.
- Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine of National Medical Products Administration, Beijing, China.
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Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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13
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Kim TJ, Lee JS, Yoon JS, Park SH, Oh MS, Jung KH, Yu KH, Lee BC, Ko SB, Yoon BW. Multiple Antiplatelet Therapy in Ischemic Stroke Already on Antiplatelet Agents Based on the Linked Big Data for Stroke. J Korean Med Sci 2023; 38:e294. [PMID: 37750368 PMCID: PMC10519784 DOI: 10.3346/jkms.2023.38.e294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/31/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Optimal antiplatelet strategy for patients with ischemic stroke who were already on single antiplatelet therapy (SAPT) remains to be elucidated. This study aimed to evaluate the effect of different antiplatelet regimens on vascular and safety outcomes at 1 year after non-cardioembolic stroke in patients previously on SAPT. METHODS We identified 9,284 patients with acute non-cardioembolic ischemic stroke that occurred on SAPT using linked data. Patients were categorized into three groups according to antiplatelet strategy at discharge: 1) SAPT; 2) dual antiplatelet therapy (DAPT); and 3) triple antiplatelet therapy (TAPT). One-year outcomes included recurrent ischemic stroke, composite outcomes (recurrent ischemic stroke, myocardial infarction, intracerebral hemorrhage, and death), and major bleeding. RESULTS Of 9,284 patients, 5,565 (59.9%) maintained SAPT, 3,638 (39.2%) were treated with DAPT, and 81 (0.9%) were treated with TAPT. Multiple antiplatelet therapy did not reduce the risks of 1-year recurrent stroke (DAPT, hazard ratio [HR], 1.08, 95% confidence interval [CI], 0.92-1.27, P = 0.339; TAPT, HR, 0.71, 95% CI, 0.27-1.91, P = 0.500) and 1-year composite outcome (DAPT, HR, 1.09, 95% CI, 0.68-1.97, P = 0.592; TAPT, HR, 1.46, 95% CI, 0.68-1.97, P = 0.592). However, the TAPT groups showed an increased risk of major bleeding complications (DAPT, HR, 1.23, 95% CI, 0.89-1.71, P = 0.208; TAPT, HR, 4.65, 95% CI, 2.01-10.74, P < 0.001). CONCLUSION Additional use of antiplatelet agents in patients with non-cardioembolic ischemic stroke who were already on SAPT did not reduce the 1-year incidence of vascular outcomes, although it increased the risk of bleeding complications.
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Affiliation(s)
- Tae Jung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ji Sung Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Sun Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Soo-Hyun Park
- Department of Neurology, Gangdong Sacred Heart Hospital, Seoul, Korea
| | - Mi Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Byung-Woo Yoon
- Department of Neurology, Uijeongbu Eulji Medical Center, Uijeongbu, Korea
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14
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Lin CJ, Chung CP, Liao NC, Chen PL, Chi NF, Lai YJ, Tang CW, Wu CH, Chang FC, Luo CB, Fay LY, Lin CF, Chou CH, Lee TH, Lee JT, Jeng JS, Lee IH. The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease. J Chin Med Assoc 2023; 86:697-714. [PMID: 37341526 DOI: 10.1097/jcma.0000000000000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.
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Affiliation(s)
- Chun-Jen Lin
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Nien-Chen Liao
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Po-Lin Chen
- Department of Neurology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Nai-Fang Chi
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yen-Jun Lai
- Radiology Department, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chih-Wei Tang
- Neurology Department and Stroke Center, Far-Eastern Memorial Hospital, New Taipei City, Taiwan, ROC
| | - Chia-Hung Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chao-Bao Luo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Li-Yu Fay
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chun-Fu Lin
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Hsing Chou
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Jiunn-Tay Lee
- Neurology Department, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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15
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Woodhouse LJ, Appleton JP, Christensen H, Dineen RA, England TJ, James M, Krishnan K, Montgomery AA, Ranta A, Robinson TG, Sprigg N, Bath PM. Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia. Sci Rep 2023; 13:11717. [PMID: 37474599 PMCID: PMC10359249 DOI: 10.1038/s41598-023-38474-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 07/09/2023] [Indexed: 07/22/2023] Open
Abstract
Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24-3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8-35 day period but not in the 0-7 or 36-90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains.Trial registration ISRCTN47823388 .
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Affiliation(s)
- Lisa J Woodhouse
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Jason P Appleton
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Hanne Christensen
- Bispebjerg and Frederiksberg Hospital, Department of Neurology, University of Copenhagen, Copenhagen, Denmark
| | - Rob A Dineen
- Radiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Queens Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
| | - Timothy J England
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Derby Stroke Centre, University Hospitals of Derby and Burton, Derby, DE22 3NE, UK
| | - Marilyn James
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Kailash Krishnan
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of Nottingham, University Park, Nottingham, NG7 2RD, UK
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
- Department of Neurology, Wellington Hospital, Wellington, New Zealand
| | - Thompson G Robinson
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, UK.
- Stroke, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK.
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16
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Zhang J, Wang A, Tian X, Meng X, Xie X, Jing J, Lin J, Wang Y, Li Z, Liu L, Li H, Jiang Y, Zhao X, Wang Y. Impact of body mass index on efficacy and safety of ticagrelor versus clopidogrel in patients with minor stroke or transient ischemic attack. CMAJ 2023; 195:E897-E904. [PMID: 37429630 PMCID: PMC10446134 DOI: 10.1503/cmaj.230262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Body mass index (BMI) may affect the response to platelet P2Y12 receptor inhibitors. We aimed to explore whether BMI influenced the efficacy and safety of ticagrelor and clopidogrel for secondary prevention of minor ischemic stroke or transient ischemic attack (TIA) among patients enrolled in the CHANCE-2 (Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II) trial. METHODS In a multicentre, randomized, double-blind, placebo-controlled trial, conducted in China, we randomized patients with minor stroke or TIA who carried the CYP2C19 loss-of-function allele to receive either ticagrelor-acetylsalicylic acid (ASA) or clopidogrel-ASA. We classified patients into obese (BMI ≥ 28) or nonobese (BMI < 28) groups. The primary efficacy outcome was stroke within 90 days, and the primary safety outcome was severe or moderate bleeding within 90 days. RESULTS Among 6412 patients, 876 were classified as obese and 5536 were classified as nonobese. Compared with clopidogrel-ASA, ticagrelor-ASA was associated with a significantly lower rate of stroke within 90 days among patients with obesity (25 [5.4%] v. 47 [11.3%]; hazard ratio [HR] 0.51, 95% confidence interval [CI] 0.30-0.87), but not among those in the nonobese group (166 [6.0%] v. 196 [7.0%]; HR 0.84, 95% CI 0.69-1.04) The interaction of treatment and BMI group was significant (p for interaction = 0.04). We did not observe any difference by BMI group in rates of severe or moderate bleeding (9 [0.3%] v. 10 [0.4%] in the nonobese group; 0 [0.0%] v. 1 [0.2%] in the obese group; p for interaction = 0.99). INTERPRETATION In this secondary analysis of a randomized controlled trial involving patients with minor ischemic stroke or TIA, compared with clopidogrel-ASA, patients with obesity received more clinical benefit from ticagrelor-ASA therapy than those without obesity. TRIAL REGISTRATION Clinicaltrials.gov, no. NCT04078737.
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Affiliation(s)
- Jia Zhang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xue Tian
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuewei Xie
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxi Lin
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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17
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Qureshi K, Farooq MU, Gorelick PB. Genotype-guided dual antiplatelet therapy in cerebrovascular disease: assessing the risk and benefits for ethnic populations. Expert Rev Cardiovasc Ther 2023; 21:621-630. [PMID: 37551687 DOI: 10.1080/14779072.2023.2245754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 08/09/2023]
Abstract
INTRODUCTION Cerebrovascular disease is a leading cause of morbidity and mortality in the world and antiplatelet therapy is a main pharmacologic means of secondary prevention. Clinical information has accumulated about benefit of dual antiplatelet therapy in certain clinical scenarios, genetic causes of antiplatelet resistance and its effect on clinical outcomes, and ethnic and geographic distributions of genetic polymorphisms. AREAS COVERED This review covers literature related to the pharmacogenomics of antiplatelet agents with a focus on ethnic variability, antiplatelet resistance, and dual antiplatelet therapy in cerebrovascular disease. EXPERT OPINION Selecting patients for dual antiplatelet therapy and specific agents require consideration of multiple factors. Ethnic factors should be considered in certain circumstances, but additional research is needed to determine the generalizability of the findings.
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Affiliation(s)
- Kasim Qureshi
- Department of Neurology, Trinity Health, Saint Mary's, Grand Rapids, MI, United States
- Department of Neurology, Michigan State University College of Human Medicine, Grand Rapids, MI, United States
| | - Muhammad U Farooq
- Department of Neurology, Trinity Health, Saint Mary's, Grand Rapids, MI, United States
- Department of Neurology, Michigan State University College of Human Medicine, Grand Rapids, MI, United States
| | - Philip B Gorelick
- Department of Neurology, Trinity Health, Saint Mary's, Grand Rapids, MI, United States
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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18
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Abstract
The health burden of ischemic stroke is high and will continue to increase with an aging population. Recurrent ischemic stroke is increasingly recognized as a major public health concern with potentially debilitating sequelae. Thus, it is imperative to develop and implement effective strategies for stroke prevention. When considering secondary ischemic stroke prevention, it is important to consider the mechanism of the first stroke and the related vascular risk factors. Secondary ischemic stroke prevention typically includes multiple medical and, potentially, surgical treatments, but with the shared goal of reducing the risk of recurrent ischemic stroke. Providers, health care systems, and insurers also need to consider the availability of treatments, their cost and patient burden, methods for improving adherence, and interventions that target lifestyle risk factors such as diet or activity. In this article, we discuss aspects from the 2021 AHA Guideline on Secondary Stroke Prevention as well as highlight additional information relevant to best practices for reducing recurrent stroke risk.
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Affiliation(s)
- Aaron Bangad
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA
| | - Mehdi Abbasi
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA
| | - Adam de Havenon
- Department of Neurology, Yale University, 15 York Street, New Haven, CT, 06510, USA.
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19
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Degjoni A, Campolo F, Stefanini L, Venneri MA. The NO/cGMP/PKG pathway in platelets: The therapeutic potential of PDE5 inhibitors in platelet disorders. J Thromb Haemost 2022; 20:2465-2474. [PMID: 35950928 PMCID: PMC9805178 DOI: 10.1111/jth.15844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/01/2022] [Accepted: 08/08/2022] [Indexed: 01/09/2023]
Abstract
Platelets are the "guardians" of the blood circulatory system. At sites of vessel injury, they ensure hemostasis and promote immunity and vessel repair. However, their uncontrolled activation is one of the main drivers of thrombosis. To keep circulating platelets in a quiescent state, the endothelium releases platelet antagonists including nitric oxide (NO) that acts by stimulating the intracellular receptor guanylyl cyclase (GC). The latter produces the second messenger cyclic guanosine-3',5'-monophosphate (cGMP) that inhibits platelet activation by stimulating protein kinase G, which phosphorylates hundreds of intracellular targets. Intracellular cGMP pools are tightly regulated by a fine balance between GC and phosphodiesterases (PDEs) that are responsible for the hydrolysis of cyclic nucleotides. Phosphodiesterase type 5 (PDE5) is a cGMP-specific PDE, broadly expressed in most tissues in humans and rodents. In clinical practice, PDE5 inhibitors (PDE5i) are used as first-line therapy for erectile dysfunction, pulmonary artery hypertension, and lower urinary tract symptoms. However, several studies have shown that PDE5i may ameliorate the outcome of various other conditions, like heart failure and stroke. Interestingly, NO donors and cGMP analogs increase the capacity of anti-platelet drugs targeting the purinergic receptor type Y, subtype 12 (P2Y12) receptor to block platelet aggregation, and preclinical studies have shown that PDE5i inhibits platelet functions. This review summarizes the molecular mechanisms underlying the effect of PDE5i on platelet activation and aggregation focusing on the therapeutic potential of PDE5i in platelet disorders, and the outcomes of a combined therapy with PDE5i and NO donors to inhibit platelet activation.
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Affiliation(s)
- Anisa Degjoni
- Department of Experimental MedicineSapienza University of RomeRomeItaly
| | - Federica Campolo
- Department of Experimental MedicineSapienza University of RomeRomeItaly
| | - Lucia Stefanini
- Department of Translational and Precision MedicineSapienza University of RomeRomeItaly
| | - Mary Anna Venneri
- Department of Experimental MedicineSapienza University of RomeRomeItaly
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20
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Wang A, Xie X, Tian X, Johnston SC, Li H, Bath PM, Zuo Y, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Meng X, Wang Y. Ticagrelor-Aspirin Versus Clopidogrel-Aspirin Among CYP2C19 Loss-of-Function Carriers With Minor Stroke or Transient Ischemic Attack in Relation to Renal Function: A Post Hoc Analysis of the CHANCE-2 Trial. Ann Intern Med 2022; 175:1534-1542. [PMID: 36315949 DOI: 10.7326/m22-1667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Evidence on the risk-benefit ratio of dual antiplatelet therapies among patients with stroke and impaired renal function is limited and inconsistent. OBJECTIVE To investigate the effect of renal function on the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin treatment. DESIGN Post hoc analysis of a multicenter, randomized, double-blind, placebo-controlled trial. (ClinicalTrials.gov: NCT04078737). SETTING 202 centers in China. PATIENTS CYP2C19 loss-of-function allele carriers with minor stroke or transient ischemic attack. INTERVENTION Ticagrelor-aspirin and clopidogrel-aspirin. MEASUREMENTS Renal function was evaluated by estimated glomerular filtration rate (eGFR) levels. The primary efficacy and safety outcomes were recurrent stroke and severe or moderate bleeding within 90 days, respectively. RESULTS Among 6378 patients, 4050 (63.5%) had normal (eGFR ≥90 mL/min/1.73 m2), 2010 (31.5%) had mildly decreased (eGFR 60 to 89 mL/min/1.73 m2), and 318 (5.0%) had moderately to severely decreased (eGFR <60 mL/min/1.73 m2) renal function. The corresponding differences in recurrent stroke between ticagrelor-aspirin and clopidogrel-aspirin for normal, mildly decreased, and moderately to severely decreased renal function was -2.8 percentage points (95% CI, -4.4 to -1.3 percentage points) (hazard ratio [HR], 0.63 [CI, 0.49 to 0.81]), -0.2 percentage point (CI, -2.4 to 2.0 percentage points) (HR, 0.98 [CI, 0.69 to 1.39]), and 3.7 percentage points (CI, -2.3 to 10.1 percentage points) (HR, 1.31 [CI, 0.48 to 3.55]), respectively. Rates of severe or moderate bleeding did not substantially differ by treatment assignments across eGFR categories. LIMITATION Renal function was only evaluated by using eGFR, and the proportion of patients with severely decreased renal function was low. CONCLUSION Patients with normal, rather than impaired, renal function received greater benefit from ticagrelor-aspirin versus clopidogrel-aspirin. PRIMARY FUNDING SOURCE Ministry of Science and Technology of the People's Republic of China.
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Affiliation(s)
- Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xue Tian
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China National Clinical Research Center for Neurological Diseases, Beijing, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, and Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China (X.T., Y.Z.)
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingting Zuo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China National Clinical Research Center for Neurological Diseases, Beijing, Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, and Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China (X.T., Y.Z.)
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, and China National Clinical Research Center for Neurological Diseases, Beijing, China (A.W., X.X., H.L., J.J., J.L., Y.W., X.Z., Z.L., Y.J., L.L., X.M.)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China National Clinical Research Center for Neurological Diseases, Beijing, and Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.W.)
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Moustafa B, Testai FD. Navigating Antiplatelet Treatment Options for Stroke: Evidence-Based and Pragmatic Strategies. Curr Neurol Neurosci Rep 2022; 22:789-802. [PMID: 36227497 DOI: 10.1007/s11910-022-01237-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The benefit of using antiplatelet monotherapy in acute ischemic stroke and secondary stroke prevention is well established. In the last few years, several large randomized trials showed that the use of short-term dual antiplatelet therapy in particular stroke subtypes may reduce the risk of recurrent ischemic events. The aim of this article is to provide a critical analysis of the current evidence and recommendations for the use of antiplatelet agents for stroke prevention. RECENT FINDINGS Long-term therapy with aspirin, clopidogrel, or aspirin plus extended-release dipyridamole is recommended for secondary stroke prevention in patients with noncardioembolic ischemic stroke. Short-term dual antiplatelet therapy with aspirin and clopidogrel is superior to antiplatelet monotherapy in secondary stroke prevention when used in patients with mild noncardioembolic stroke or high-risk transient ischemic attack. Dual therapy, however, is associated with an increased risk of major bleeding, particularly when the treatment is extended for greater than 30 days. Similarly, aspirin plus ticagrelor is superior to aspirin monotherapy for the prevention of recurrent ischemic stroke, although this combination is associated with a higher risk of hemorrhagic complications when compared to other dual antiplatelet regimens. Among patients who carry CYP2C19 genetic polymorphisms associated with a slow bioactivation of clopidogrel, short-term treatment with aspirin plus ticagrelor is superior to aspirin plus clopidogrel for the reduction of recurrent stroke; however, the use of ticagrelor is associated with a higher risk of any bleeding. In patients with symptomatic intracranial stenosis, aggressive medical management in addition to dual antiplatelet therapy up to 90 days is recommended. Antiplatelet therapy has an essential role in the management of ischemic stroke. The specific antiplatelet regimen should be individualized based on the stroke characteristics, time from symptom onset, and patient-specific predisposition to develop hemorrhagic complications.
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Affiliation(s)
- Bayan Moustafa
- Mayo Clinic College of Medicine and Science, 1221 Whipple St, Eau Claire, WI, 54703, USA.
| | - Fernando D Testai
- College of Medicine, University of Illinois at Chicago, 912 S Wood St, Chicago, IL, 60612, USA
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22
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Naoxintong Capsule for Secondary Prevention of Ischemic Stroke: A Multicenter, Randomized, and Placebo-Controlled Trial. Chin J Integr Med 2022; 28:1063-1071. [PMID: 36251140 DOI: 10.1007/s11655-022-3586-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine whether the combination of Naoxintong Capsule with standard care could further reduce the recurrence of ischemic stroke without increasing the risk of severe bleeding. METHODS A total of 23 Chinese medical centers participated in this trial. Adult patients with a history of ischemic stroke were randomly assigned in a 1:1 ratio using a block design to receive either Naoxintong Capsule (1.2 g orally, twice a day) or placebo in addition to standard care. The primary endpoint was recurrence of ischemic stroke within 2 years. Secondary outcomes included myocardial infarction, death due to recurrent ischemic stroke, and all-cause mortality. The safety of drugs was monitored. Results were analyzed using the intention-to-treat principle. RESULTS A total of 2,200 patients were enrolled from March 2015 to March 2016, of whom 143 and 158 in the Naoxintong and placebo groups were lost to follow-up, respectively. Compared with the placebo group, the recurrence rate of ischemic stroke within 2 years was significantly lower in the Naoxintong group [6.5% vs. 9.5%, hazard ratio (HR): 0.665, 95% confidence interval (CI): 0.492-0.899, P=0.008]. The two groups showed no significant differences in the secondary outcomes and safety, including rates of severe hemorrhage, cerebral hemorrhage and subarachnoid hemorrhage (P>0.05). CONCLUSION The combination of Naoxintong Capsule with standard care reduced the 2-year stroke recurrence rate in patients with ischemic stroke without increasing the risk of severe hemorrhage in high-risk patients. (Trial registration No. NCT02334969).
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23
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Viola P, Gioacchini FM, Astorina A, Pisani D, Scarpa A, Marcianò G, Casarella A, Basile E, Rania V, Re M, Chiarella G. The pharmacological treatment of acute vestibular syndrome. Front Neurol 2022; 13:999112. [PMID: 36158968 PMCID: PMC9500199 DOI: 10.3389/fneur.2022.999112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/17/2022] [Indexed: 11/21/2022] Open
Abstract
Acute vestibular syndrome (AVS) represents a clinical picture that involves urgent management due to the important procession of symptoms accompanying the event, which can be positively or negatively influenced by therapeutic choices and intervention timing. This forces a differential diagnosis and therapeutic choices to be made in conditions that are not always favorable and often not in the specialist field. In this work, we will examine in detail the pharmacological therapeutic possibilities, correlating them to the differential and, as far as possible, to the etiological diagnosis. In particular, the pharmacological possibilities for the two main conditions we can face will be investigated, namely, vestibular neuritis and posterior circulation stroke.
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Affiliation(s)
- Pasquale Viola
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, Catanzaro, Italy
| | - Federico Maria Gioacchini
- ENT Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Alessia Astorina
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, Catanzaro, Italy
| | - Davide Pisani
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, Catanzaro, Italy
| | - Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
- *Correspondence: Alfonso Scarpa
| | - Gianmarco Marcianò
- Department of Health Science, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Alessandro Casarella
- Department of Health Science, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Emanuele Basile
- Department of Health Science, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Vincenzo Rania
- Department of Health Science, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Massimo Re
- ENT Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, Catanzaro, Italy
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24
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Krishnan K, Law ZK, Minhas JS, Bath PM, Robinson TG, Sprigg N, Mavilakandy A, England TJ, Eveson D, Mistri A, Dawson J, Appleton JP. Antiplatelet treatment for acute secondary prevention of non-cardioembolic minor stroke / transient ischaemic attack: an update for the acute physician. Clin Med (Lond) 2022; 22:449-454. [PMID: 38589066 PMCID: PMC9595021 DOI: 10.7861/clinmed.2021-0597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute stroke is the leading cause of disability in the UK and a leading cause of mortality worldwide. The majority of patients with ischaemic stroke present with minor deficits or transient ischaemic attack (TIA), and are often first seen by patient-facing clinicians. Urgent evaluation and treatment are important as many patients are at high risk of major vascular events and death within hours to days after the index event. This narrative review summarises the evidence on four antiplatelet treatments for non-cardioembolic stroke prevention: aspirin, clopidogrel, dipyridamole and ticagrelor. Each of these drugs has a unique mechanism and has been tested as a single agent or in combination. Aspirin, when given early is beneficial and short-term treatment with aspirin and clopidogrel has been shown to be more effective in high-risk TIA / minor stroke. This review concludes by highlighting gaps in evidence, including scope for future trials that could potentially change clinical practice.
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Affiliation(s)
| | - Zhe Kang Law
- National University of Malaysia, Kuala Lumpur, Malaysia
| | - Jatinder S Minhas
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | - Thompson G Robinson
- University of Leicester, Leicester, UK and Leicester Royal Infirmary, Leicester, UK
| | | | | | - Timothy J England
- Queen's Medical Centre, Nottingham, UK and Royal Derby Hospital, Derby, UK
| | | | | | - Jesse Dawson
- University of Glasgow College of Medical, Veterinary and Life Sciences, Glasgow, UK and Queen Elizabeth University Hospital, Glasgow, UK
| | - Jason P Appleton
- Queen Elizabeth Hospital, Birmingham, UK and University of Birmingham College of Dental and Medical Sciences, Birmingham, UK
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25
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Chen PL, Chen YJ, Chung CP, Seak CJ, Jeng JS, Hsieh MJ, Lien LM, Chen JH, Chen YW, Chiu TF, Lee JT, Ng CJ. Dual Antiplatelet Therapy in the Management of Acute Minor Ischemic Stroke and High-Risk Transient Ischemic Attack: An Expert Consensus Statement From Taiwan Stroke Society and Taiwan Society of Emergency Medicine. J Acute Med 2022; 12:85-95. [PMID: 36313610 PMCID: PMC9561483 DOI: 10.6705/j.jacme.202209_12(3).0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 07/24/2022] [Indexed: 06/16/2023]
Abstract
The aim of this review is to achieve a consensus between Taiwan Stroke Society (TSS) and Taiwan Society of Emergency Medicine (TSEM) to manage acute non-cardioembolic minor ischemic stroke (MIS) and high-risk transient ischemic attack (TIA). The methodology is to review the recent findings from clinical trials of dual antiplatelet therapy (DAPT) from 2010 to 2021 and updates in clinical practice guidelines from 2018 to 2022 for non-cardioembolic MIS/TIA management at the acute stage. Four leading clinical studies, CHANCE, POINT, THALES, and CHANCE-2 along with other relevant studies introducing DAPT, are discussed in this review. The risk-benefit profile between stroke recurrence reduction and major bleeding increase is also elucidated. TSS and TSEM concluded that for patients presenting with non-cardioembolic MIS or high-risk TIA who did not receive intravenous alteplase, initiation of DAPT within 24 hours after stroke onset and continued up to 21 days, followed by antiplatelet monotherapy, is effective in reducing recurrent ischemic stroke for a period of up to 90 days.
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Affiliation(s)
- Po-Lin Chen
- Neurological Institute Division of Neurology Taichung Veterans General Hospital, Taichung Taiwan
| | - Ying-Ju Chen
- Taipei Veterans General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Chih-Ping Chung
- Neurological Institute Department of Neurology Taipei Veterans General Hospital, Taipei Taiwan
| | - Chen-June Seak
- New Taipei Municipal Tucheng Hospital Department of Emergency Medicine New Taipei City Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Jiann-Shing Jeng
- National Taiwan University Hospital Department of Neurology and Stroke Center Taipei Taiwan
| | - Ming-Ju Hsieh
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
| | - Li-Ming Lien
- Shin Kong Wu Ho-Su Memorial Hospital Department of Neurology Taipei Taiwan
| | - Jiann-Hwa Chen
- Cathay General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Yu-Wei Chen
- Landseed International Hospital Department of Neurology Taoyuan Taiwan
| | - Te-Fa Chiu
- China Medical University Hospital Department of Emergency Medicine Taichung Taiwan
| | - Jiunn-Tay Lee
- Tri-Service General Hospital Department of Neurology National Defense Medical Center, Taipei Taiwan
| | - Chip-Jin Ng
- Chang Gung University College of Medicine Taoyuan Taiwan
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
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26
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Scalia L, Calderone D, Capodanno D. Antiplatelet therapy after acute ischemic stroke or transient ischemic attack. Expert Rev Clin Pharmacol 2022; 15:1027-1038. [DOI: 10.1080/17512433.2022.2118713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
| | - Dario Calderone
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
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27
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McDermott JH, Leach M, Sen D, Smith CJ, Newman WG, Bath PM. The role of CYP2C19 genotyping to guide antiplatelet therapy following ischemic stroke or transient ischemic attack. Expert Rev Clin Pharmacol 2022; 15:811-825. [PMID: 35912831 PMCID: PMC9612933 DOI: 10.1080/17512433.2022.2108401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Clopidogrel is an antiplatelet agent recommended for secondary prevention of ischemic stroke (IS) and transient ischemic attack (TIA). Conversion of clopidogrel to its active metabolite by hepatic cytochrome P450-2C19 (CYP2C19) is essential for the inhibition of the P2Y12 receptor and subsequent platelet aggregation to prevent thrombotic events. CYP2C19 is highly polymorphic, with over 30 loss of function (LoF) alleles. This review considers whether there is sufficient data to support genotype guided antiplatelet therapy after stroke. Areas covered A systematic literature review retrieved articles, which describe the interaction between CYP2C19 genotype and clinical outcomes following IS or TIA when treated with clopidogrel. The review documents efforts to identify optimal antiplatelet regimens and explores the value genotype guided antiplatelet therapy. The work outlines the contemporary understanding of clopidogrel metabolism and appraises evidence linking CYP2C19 LoF variants with attenuated platelet inhibition and poorer outcomes. Expert opinion There is good evidence that CYP2C19 LoF allele carriers of Han-Chinese ancestry have increased risk for further vascular events following TIA or IS when treated with clopidogrel. The evidence base is less certain in other populations. The expansion of pharmacogenetics into routine clinical practice will facilitate further research and help tailor other aspects of secondary prevention.
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Affiliation(s)
- John H McDermott
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,The Division of Evolution, Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Marc Leach
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK
| | - Dwaipayan Sen
- Greater Manchester Comprehensive Stroke Centre, Geoffrey Jefferson Brain Research Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Geoffrey Jefferson Brain Research Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK.,Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - William G Newman
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,The Division of Evolution, Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
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28
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Yi T, Zhan A, Wu Y, Li Y, Zheng X, Lin D, Lin X, Pan Z, Chen R, Parsons M, Chen W, Lin L. Endovascular Treatment of ICAS Patients: Targeting Reperfusion Rather than Residual Stenosis. Brain Sci 2022; 12:brainsci12080966. [PMID: 35892407 PMCID: PMC9332149 DOI: 10.3390/brainsci12080966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 07/14/2022] [Accepted: 07/16/2022] [Indexed: 02/05/2023] Open
Abstract
Background and Purpose: Previous studies showed that acute reocclusion after endovascular therapy is related to residual stenosis. However, we observed that reperfusion status but not residual stenosis severity is related to acute reocclusion. This study aimed to assess which factor mention above is more likely to be associated with artery reocclusion after endovascular treatment. Methods: This study included 86 acute ischemic stroke patients who had middle cerebral artery (MCA) atherosclerotic occlusions and received endovascular treatment within 24 h of a stroke. The primary outcomes included intraprocedural reocclusion assessed during endovascular treatment and delayed reocclusion assessed through follow-up angiography. Results: Of the 86 patients, the intraprocedural reocclusion rate was 7.0% (6/86) and the delayed reocclusion rate was 2.3% (2/86). Regarding intraprocedural occlusion, for patients with severe residual stenosis, patients with successful thrombectomy reperfusion showed a significantly lower rate than unsuccessful thrombectomy reperfusion (0/30 vs. 6/31, p = 0.003); on the other hand, for patients with successful thrombectomy reperfusion, patients with severe residual stenosis showed no difference from those with mild to moderate residual stenosis in terms of intraprocedural occlusion (0/30 vs. 0/25, p = 1.00). In addition, after endovascular treatment, all patients achieved successful reperfusion. There was no significant difference in the delayed reocclusion rate between patients with severe residual stenosis and those with mild to moderate residual stenosis (2/25 vs. 0/61, p = 0.085). Conclusion: Reperfusion status rather than residual stenosis severity is associated with artery reocclusion after endovascular treatment. Once successful reperfusion was achieved, the reocclusion occurrence was fairly low in MCA atherosclerosis stroke patients, even with severe residual stenosis.
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Affiliation(s)
- Tingyu Yi
- Cerebrovascular and Neuro-Intervention Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (T.Y.); (Y.W.); (X.Z.); (D.L.); (X.L.); (Z.P.); (R.C.)
| | - Alai Zhan
- Radiology Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (A.Z.); (Y.L.)
| | - Yanmin Wu
- Cerebrovascular and Neuro-Intervention Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (T.Y.); (Y.W.); (X.Z.); (D.L.); (X.L.); (Z.P.); (R.C.)
| | - Yimin Li
- Radiology Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (A.Z.); (Y.L.)
| | - Xiufen Zheng
- Cerebrovascular and Neuro-Intervention Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (T.Y.); (Y.W.); (X.Z.); (D.L.); (X.L.); (Z.P.); (R.C.)
| | - Dinglai Lin
- Cerebrovascular and Neuro-Intervention Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (T.Y.); (Y.W.); (X.Z.); (D.L.); (X.L.); (Z.P.); (R.C.)
| | - Xiaohui Lin
- Cerebrovascular and Neuro-Intervention Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (T.Y.); (Y.W.); (X.Z.); (D.L.); (X.L.); (Z.P.); (R.C.)
| | - Zhinan Pan
- Cerebrovascular and Neuro-Intervention Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (T.Y.); (Y.W.); (X.Z.); (D.L.); (X.L.); (Z.P.); (R.C.)
| | - Rongcheng Chen
- Cerebrovascular and Neuro-Intervention Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (T.Y.); (Y.W.); (X.Z.); (D.L.); (X.L.); (Z.P.); (R.C.)
| | - Mark Parsons
- Department of Neurology and Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC 3050, Australia;
| | - Wenhuo Chen
- Cerebrovascular and Neuro-Intervention Department, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou 363000, China; (T.Y.); (Y.W.); (X.Z.); (D.L.); (X.L.); (Z.P.); (R.C.)
- Correspondence: (W.C.); (L.L.); Tel.: +86-13806906089 (W.C.); +86-13777446074 (L.L.)
| | - Longting Lin
- Department of Neurology and Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC 3050, Australia;
- Correspondence: (W.C.); (L.L.); Tel.: +86-13806906089 (W.C.); +86-13777446074 (L.L.)
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Lim S, Murphy S, Murphy S, Coughlan T, O'Neill D, Tierney S, Egan B, Collins D, McCarthy A, Lim SY, Smith D, Cox D, McCabe D. Assessment of on-treatment platelet reactivity at high and low shear stress and platelet activation status after the addition of dipyridamole to aspirin in the early and late phases after TIA and ischaemic stroke. J Neurol Sci 2022; 441:120334. [DOI: 10.1016/j.jns.2022.120334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 05/30/2022] [Accepted: 06/30/2022] [Indexed: 11/24/2022]
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Chen DQ, Guo Y, Li X, Zhang GQ, Li P. Small molecules as modulators of regulated cell death against ischemia/reperfusion injury. Med Res Rev 2022; 42:2067-2101. [PMID: 35730121 DOI: 10.1002/med.21917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 11/11/2021] [Accepted: 06/07/2022] [Indexed: 12/13/2022]
Abstract
Ischemia/reperfusion (IR) injury contributes to disability and mortality worldwide. Due to the complicated mechanisms and lack of proper therapeutic targets, few interventions are available that specifically target the pathogenesis of IR injury. Regulated cell death (RCD) of endothelial and parenchymal cells is recognized as the promising intervening target. Recent advances in IR injury suggest that small molecules exhibit beneficial effects on various RCD against IR injury, including apoptosis, necroptosis, autophagy, ferroptosis, pyroptosis, and parthanatos. Here, we describe the mechanisms behind these novel promising therapeutic targets and explain the machinery powering the small molecules. These small molecules exert protection by targeting endothelial or parenchymal cells to alleviate IR injury. Therapies of the ideal combination of small molecules targeting multiple cell types have shown potent synergetic therapeutic effects, laying the foundation for novel strategies to attenuate IR injury.
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Affiliation(s)
- Dan-Qian Chen
- Department of Emergency, China-Japan Friendship Hospital, Beijing, China.,Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Yan Guo
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Xin Li
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Guo-Qiang Zhang
- Department of Emergency, China-Japan Friendship Hospital, Beijing, China
| | - Ping Li
- Beijing Key Lab for Immune-Mediated Inflammatory Diseases, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
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Pan Y, Meng X, Jin A, Johnston SC, Li H, Bath PM, Xie X, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Yang H, Cheng J, Wang Z, Wang Y. Time Course for Benefit and Risk With Ticagrelor and Aspirin in Individuals With Acute Ischemic Stroke or Transient Ischemic Attack Who Carry CYP2C19 Loss-of-Function Alleles: A Secondary Analysis of the CHANCE-2 Randomized Clinical Trial. JAMA Neurol 2022; 79:739-745. [PMID: 35727586 DOI: 10.1001/jamaneurol.2022.1457] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Dual antiplatelet therapy (DAPT) with ticagrelor and aspirin has been found to be effective for secondary prevention after minor ischemic stroke or transient ischemic attack (TIA) in individuals who carry CYP2C19 loss-of-function (LOF) alleles; however, uncertainties remain about the time course of benefit and risk with ticagrelor and aspirin in these patients. Objective To obtain time-course estimates of efficacy and risk with ticagrelor and aspirin after minor stroke or TIA in individuals with CYP2C19 LOF alleles. Design, Setting, and Participants The Ticagrelor or Clopidogrel With Aspirin in High-risk Patients With Acute Nondisabling Cerebrovascular Events II (CHANCE-2) randomized clinical trial enrolled patients 40 years and older from 202 hospitals in China with acute minor stroke or TIA who carried CYP2C19 LOF alleles between September 23, 2019, and March 22, 2021, and were followed up for 90 days. All 6412 patients enrolled in the CHANCE-2 trial were included in this secondary analysis. Data were analyzed in October 2021. Interventions Ticagrelor (180 mg on day 1 followed by 90 mg twice daily on days 2-90) or clopidogrel (300 mg on day 1 followed by 75 mg daily on days 2-90). All patients received aspirin (75-300 mg on day 1 followed by 75 mg daily for 21 days). Main Outcomes and Measures The efficacy outcome was major ischemic event, defined as the composite of ischemic stroke or nonhemorrhagic death. Safety outcomes included moderate to severe bleeding and any bleeding. Results A total of 6412 patients were included (3205 in the ticagrelor and aspirin group and 3207 in the clopidogrel and aspirin group). The median (IQR) age was 65 (57-71) years, and 4242 patients (66%) were men. The reduction of major ischemic events with ticagrelor and aspirin predominately occurred in the first week (absolute risk reduction, 1.34%; 95% CI, 0.29 to 2.39) and attenuated but remained in the next 3 weeks (absolute risk reduction in the second week, 0.11%; 95% CI, -0.24 to 0.45; absolute risk reduction in the third week, 0.14%; 95% CI, -0.11 to 0.38; absolute risk reduction in the fourth week, 0.04%; 95% CI, -0.18 to 0.25). The risk of moderate to severe bleeding was consistently low in the ticagrelor and aspirin group. The absolute increase in any bleeding seen in the first week (0.87%; 95% CI, 0.25 to 1.50) remained in the next 3 weeks (absolute increase in the second week, 1.21%; 95% CI, 0.75 to 1.68; absolute increase in the third week, 0.33%; 95% CI, -0.05 to 0.72; absolute increase in the fourth week, 0.23%; 95% CI, -0.03 to 0.49). Conclusion and Relevance Among patients with minor stroke or TIA who carried CYP2C19 LOF alleles, benefit with ticagrelor and aspirin was present predominately in the first week, with additional small benefit accruing in the next 2 weeks.
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Affiliation(s)
- Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Aoming Jin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongqin Yang
- Department of Neurology, Jiyuan Hospital of Traditional Chinese Medicine, Henan, China
| | - Jiwei Cheng
- Department of Neurology, Putuo District Central Hospital, Shanghai, China
| | - Zhimin Wang
- Department of Neurology, Taizhou First People's Hospital, Zhejiang, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
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Wang A, Meng X, Tian X, Johnston SC, Li H, Bath PM, Zuo Y, Xie X, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Wang F, Wang Y, Huang P, Chen G, Wang Y. Effect of Hypertension on Efficacy and Safety of Ticagrelor-Aspirin Versus Clopidogrel-Aspirin in Minor Stroke or Transient Ischemic Attack. Stroke 2022; 53:2799-2808. [PMID: 35656824 DOI: 10.1161/strokeaha.122.038662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypertension is a risk factor of poor stroke outcomes and associated with antiplatelet resistance. This study aimed to explore the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in patients with different hypertension status, using randomized trial data from the CHANCE-2 trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II). METHODS A total of 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles were enrolled and randomized to either ticagrelor-aspirin or clopidogrel-aspirin group. Hypertension status were classified into no, newly diagnosed, and previously diagnosed hypertension according to medical history, blood pressure, and antihypertensive medications during hospitalization. The primary efficacy and safety outcomes were stroke recurrence and moderate to severe bleeding risk within 90-day follow-up. RESULTS Ticagrelor-aspirin was associated with reduced risk of new stroke in patients without hypertension (32 [4.8%] versus 60 [7.2%]; hazard ratio, 0.55 [95% CI, 0.35-0.86]), but not in those with a newly diagnosed hypertension (20 [5.3%] versus 36 [9.1%]; hazard ratio 0.59 [95% CI, 0.33-1.07]), or those with a previously diagnosed hypertension (139 [7.0%] versus 147 [7.4%]; hazard ratio, 0.93 [95% CI, 0.74-1.18]) compared with clopidogrel-aspirin (P=0.04 for interaction). The risk of bleeding for ticagrelor-aspirin was not associated with hypertension status (0.1% versus 0.4%; 0.3% versus 0.5%, 0.4% versus 0.3%, P=0.50 for interaction). All the efficacy and safety outcomes between treatments did not differ by blood pressure levels on admission. CONCLUSIONS In the CHANCE-2 trial, patients without hypertension received a significantly greater benefit from ticagrelor- aspirin than those with previous hypertension after minor stroke or transient ischemic attack, and a similar benefit trend was observed in those with newly diagnosed hypertension. REGISTRATION URL: http://www. CLINICALTRIALS gov; Unique identifier: NCT04078737.
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Affiliation(s)
- Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Xue Tian
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (X.T., Y.Z.).,Beijing Municipal Key Laboratory of Clinical Epidemiology, China (X.T., Y.Z.)
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
| | - Yingting Zuo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (X.T., Y.Z.).,Beijing Municipal Key Laboratory of Clinical Epidemiology, China (X.T., Y.Z.)
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Feng Wang
- Departments of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, China (F.W.)
| | - Yanxia Wang
- Department of Neurology, Hejian People's Hospital, Hebei, China (Y.W.)
| | - Panbing Huang
- Department of Neurology, The third People's Hospital in Tongzhou District of Nantong, Jiangsu, China (P.H.)
| | - Guofang Chen
- Department of Neurology, Xuzhou Central Hospital, Jiangsu, China (G.C.)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
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Verhoeven JI, van Lith TJ, Ekker MS, Hilkens NA, Maaijwee NA, Rutten-Jacobs LCA, Klijn CJ, Leeuw FED. Long-term Risk of Bleeding and Ischemic Events After Ischemic Stroke or Transient Ischemic Attack in Young Adults. Neurology 2022; 99:e549-e559. [PMID: 35654598 DOI: 10.1212/wnl.0000000000200808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 04/08/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Guidelines recommend antithrombotic medication as secondary prevention for patients with ischemic stroke or TIA at young age based on results from trials in older patients. We investigated the long-term risk of bleeding and ischemic events in young patients after ischemic stroke or TIA. METHODS We included 30-day survivors of first-ever ischemic stroke or TIA aged 18-50 years from the FUTURE study, a prospective cohort study of stroke at young age. We obtained information on recurrent ischemia based on structured data collection from 1995 until 2014 as part of the FUTURE study follow-up, complemented with information on any bleeding and ischemic events by retrospective chart review from baseline until last medical consultation or June 2020. Primary outcome was any bleeding, secondary outcome any ischemic event during follow-up. Both were stratified for sex, age, etiology, and use of antithrombotic medication at discharge. Bleeding and ischemic events were classified according to location and bleeding events also by severity. RESULTS We included 544 patients (56.1% women, median age of 42.2; interquartile range [IQR] 36.5-46.7 years) with a median follow-up of 9.6 (IQR 2.5-14.3) years. Ten-year cumulative risk of any bleeding event was 21.8% (95% confidence interval [CI] 17.4-26.0) and 33.9% (95% CI 28.3-37.5) of any ischemic event. Risk of bleeding was higher in women with a cumulative risk of 28.2% (95% CI 21.6-34.3) versus 13.7% (95% CI 8.2-18.9) in men (p<0.01), mainly due to gynecological bleeds. Female sex (p<0.001) and age between 40 and 49 years old (p=0.04) were independent predictors of bleeding. DISCUSSION Young patients after ischemic stroke or TIA have a substantial long-term risk of both bleeding (especially women) and ischemic events. Future studies should investigate the effects of long-term antithrombotics in young patients, taking into account the risk of bleeding complications.
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Affiliation(s)
- Jamie Inge Verhoeven
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology, Nijmegen; The Netherlands
| | - Theresa J van Lith
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology, Nijmegen; The Netherlands
| | - Merel S Ekker
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology, Nijmegen; The Netherlands
| | - Nina A Hilkens
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology, Nijmegen; The Netherlands
| | | | - Loes C A Rutten-Jacobs
- Luzerner Kantonsspital; Neurocentre, Department of Neurology and Neurorehabilitation; Luzern; Switzerland
| | - Catharina Jm Klijn
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology, Nijmegen; The Netherlands
| | - Frank-Erik de Leeuw
- Radboud University Medical Centre; Donders Institute for Brain, Cognition and Behaviour; Department of Neurology, Nijmegen; The Netherlands
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Pomero F, Galli E, Bellesini M, Maroni L, Squizzato A. P2Y12 inhibitors plus aspirin for acute treatment and secondary prevention in minor stroke and high-risk transient ischemic attack: A systematic review and meta-analysis. Eur J Intern Med 2022; 100:46-55. [PMID: 35331593 DOI: 10.1016/j.ejim.2022.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Aspirin is a cornerstone of preventive treatment for stroke recurrence, but during the last few years the role of dual antiplatelet therapy (DAPT) is much more emerging. OBJECTIVE This systematic review aimed to compare early use of P2Y12 inhibitors (clopidogrel/ticagrelor) plus aspirin to aspirin alone for acute treatment and secondary prevention in acute non-cardioembolic minor ischemic stroke or TIA. METHODS A systematic search on MEDLINE and EMBASE was performed. Treatment effects were estimated with RRs and 95% CI. We used RevMan 5.4 for data analyses. We assessed methodological quality of selected studies according to Rob2 tools and quality of evidence with GRADE approach. RESULTS Four RCTs were included, enrolling 21,459 patients. Compared to aspirin alone, DAPT was superior in reducing stroke recurrence (RR 0.74, 95% CI 0.67-0.82, P <0.00001, absolute risk difference by 2%, NNT 50) and disabling stroke defined as mRS>2 (RR 0.84, 95% CI 0.75-0.95, P = 0.004), with no impact on all causes of mortality (RR 1.30, 95% CI 0.90-1.89, P = 0.16). An increased risk of major bleeding was emerged (RR 2.54, 95% CI 1.65-3.92, P <0.0001, absolute risk difference by 0,4%, NNH 250), in particular with ticagrelor, but there was no correlation between therapy duration and bleeding risk, as appeared from one-month (RR 3.06, 95% CI 1.64 to 5.69) and three-month (RR 2.09, 95% CI 1.18 to 3.69) follow-up analysis. CONCLUSIONS Early administration of P2Y12 inhibitors plus aspirin in patients with acute non-cardioembolic minor ischemic stroke or TIA reduced the incidence of ischemic stroke recurrence, impacting more significantly than the increased bleeding risk and influencing patients' quality of life by reducing disabling stroke.
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Affiliation(s)
- Fulvio Pomero
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy
| | - Eleonora Galli
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy; Department of Internal Medicine, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy.
| | - Marta Bellesini
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Lorenzo Maroni
- Department of General Medicine, Hypertension Dyslipidemia and Cardiovascular Risk Clinic, ASST Valle Olona, Sant'Antonio Abate Hospital, Via Eusebio Pastori, 21013 Gallarate, VA, Italy; Ospedale di Circolo, Via Arnaldo da Brescia 1, 21052 Busto Arsizio, VA, Italy
| | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
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Mosconi MG, Paciaroni M, Ageno W. Investigational drugs for ischemic stroke: what's in the clinical development pipeline for acute phase and prevention? Expert Opin Investig Drugs 2022; 31:645-667. [PMID: 35486110 DOI: 10.1080/13543784.2022.2072725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Stroke is a leading cause of disability and mortality and its burden expected to increase. The only approved drug for acute ischemic stroke is the intravenous thrombolytic alteplase. The risk of bleeding complications is one of the reasons for the undertreatment of eligible patients. Numerous drugs are currently being developed to improve safety-efficacy. AREAS COVERED We reviewed literature from January 1st, 2000, to 15th January 2022 for the development and testing of novel drugs with the aim of targeting treatment at prevention of ischemic stroke: PubMed, MEDLINE, Google Scholar, and ClinicalTrial.gov. EXPERT OPINION The pathophysiology of ischemic stroke involves multiple pathways causing cerebral artery obstruction and brain tissue ischemia. Data suggest that tenecteplase is a more promising fibrinolytic agent with a superior efficacy-safety profile, compared to the currently approved alteplase. Current guidelines consider a short-term cycle of mannitol or hypertonic saline to be advisable in patients with space-occupying hemispheric infarction. Regarding primary and secondary prevention, research is primarily focused on identifying mechanisms to improve the safety-efficacy profile using a "hemostasis-sparing" approach. Further evaluation on those agents that have already shown promise for their risk/benefit profiles, would benefit greatly a neurologist's capacity to successfully prevent and treat ischemic stroke patients.
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Affiliation(s)
- Maria Giulia Mosconi
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Maurizio Paciaroni
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Shah J, Liu S, Yu W. Contemporary antiplatelet therapy for secondary stroke prevention: a narrative review of current literature and guidelines. Stroke Vasc Neurol 2022; 7:406-414. [PMID: 35393359 DOI: 10.1136/svn-2021-001166] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 02/16/2022] [Indexed: 11/04/2022] Open
Abstract
Antiplatelet therapy is one of the mainstays for secondary stroke prevention. This narrative review aimed to highlight the current evidence and recommendations of antiplatelet therapy for stroke prevention.We conducted advanced literature search for antiplatelet therapy. Landmark studies and randomised controlled trials evaluating antiplatelet therapy for secondary stroke prevention are reviewed. Results from Cochrane systematic review, pooled data analysis and meta-analysis are discussed.Single-antiplatelet therapy (SAPT) with aspirin, aspirin/extended-release dipyridamole or clopidogrel reduces the risk of recurrent ischaemic stroke in patients with non-cardioembolic ischaemic stroke or transient ischaemic attack (TIA). Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute noncardioembolic ischaemic stroke or high-risk TIA. Prolonged use of DAPT is associated with higher risk of haemorrhage without reduction in stroke recurrence than SAPT. Compared with placebo, aspirin reduces the relative risk of recurrent stroke by approximately 22%. Aspirin/dipyridamole and cilostazol are superior to aspirin but associated with significant side effects. Cilostazol or ticagrelor might be more effective than aspirin or clopidogrel in patients with intracranial stenosis.SAPT is indicated for secondary stroke prevention in patients with non-cardioembolic ischaemic stroke or TIA. DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days followed by SAPT is recommended for patients with minor acute noncardioembolic stroke or high-risk TIA. Selection of appropriate antiplatelet therapy should also be based on compliance, drug tolerance or resistance.
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Affiliation(s)
- Jay Shah
- Neurology, University of California, Irvine, California, USA
| | - Shimeng Liu
- Neurology, University of California, Irvine, California, USA.,Neurology, Tiantan Hospital, Beijing, China
| | - Wengui Yu
- Neurology, University of California, Irvine, California, USA
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Veunac L, Saliou G, Knebel JF, Bartolini B, Puccinelli F, Michel P, Hajdu SD. Revascularization of carotid artery occlusion using stenting versus non stenting in endovascular management of tandem occlusion stroke. J Clin Neurosci 2022; 98:15-20. [DOI: 10.1016/j.jocn.2022.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 12/19/2021] [Accepted: 01/25/2022] [Indexed: 10/19/2022]
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Fan H, Wang Y, Liu T, Zhang K, Ren J, Li Y, Li J, Wu X, Li X, Niu X. Dual versus mono antiplatelet therapy in mild‐to‐moderate stroke during hospitalization. Ann Clin Transl Neurol 2022; 9:506-514. [PMID: 35278046 PMCID: PMC8994979 DOI: 10.1002/acn3.51541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 01/11/2022] [Accepted: 02/21/2022] [Indexed: 11/09/2022] Open
Abstract
Objective Subsequent vascular events are common after acute ischemic stroke during hospitalization. This study aimed to analyze the effectiveness of combination therapy with clopidogrel and aspirin among mild‐to‐moderate ischemic stroke patients treated within 72 h on the basis of a high‐intensity dose of statins. Methods In a retrospective and multicenter cohort study, acute (within 72 h of onset) mild‐to‐moderate stroke patients were divided into aspirin and clopidogrel‐aspirin groups on the basis of a high‐intensity dose of statin therapy. The primary outcome was compound vascular events during hospitalization. Cox's proportional hazards model was used to assess differences, with the study center as a random effect. Results Among the 506 patients meeting the eligibility criteria, all subjects received a high‐intensity dose of statins, including 20 mg rosuvastatin or 40 mg atorvastatin while in the hospital. In an unadjusted analysis, compound vascular events occurred in 7.2% of patients in the clopidogrel‐aspirin group compared with 13.7% of those in the aspirin group (p = 0.022). In a Cox proportional hazards regression analysis, clopidogrel‐aspirin was associated with a lower risk of compound vascular events (hazard ratio [95% CI], 0.47 [0.25–0.87]; p = 0.017) and ischemic vascular events (p = 0.008). Moderate and severe hemorrhage occurred in four patients (1.07%) in the clopidogrel‐aspirin group and three patients (2.30%) in the aspirin group (p = 0.626). Interpretation In this study based on high‐intensity statin therapy, clopidogrel‐aspirin reduced the risk of compound vascular events and did not increase the risk of hemorrhage during patients' hospitalization after mild‐to‐moderate ischemic stroke within 72 h.
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Affiliation(s)
- Haimei Fan
- Department of Neurology First Hospital of Shanxi Medical University Taiyuan Shanxi Province 030001 China
- Department of Neurology General Hospital of Tisco (Sixth Hospital of Shanxi Medical University) Taiyuan 030008 China
| | - Yongle Wang
- Department of Neurology First Hospital of Shanxi Medical University Taiyuan Shanxi Province 030001 China
| | - Tingting Liu
- Department of Neurology First Hospital of Shanxi Medical University Taiyuan Shanxi Province 030001 China
| | - Kaili Zhang
- Department of Neurology Shanxi Bethune Hospital (Third Hospital of Shanxi Medical University) Taiyuan 030032 China
| | - Jing Ren
- Department of Neurology First Hospital of Shanxi Medical University Taiyuan Shanxi Province 030001 China
| | - Yanan Li
- Department of Neurology First Hospital of Shanxi Medical University Taiyuan Shanxi Province 030001 China
| | - Juan Li
- Department of Neurology First Hospital of Shanxi Medical University Taiyuan Shanxi Province 030001 China
| | - Xuemei Wu
- Department of Neurology General Hospital of Tisco (Sixth Hospital of Shanxi Medical University) Taiyuan 030008 China
| | - Xinyi Li
- Department of Neurology Shanxi Bethune Hospital (Third Hospital of Shanxi Medical University) Taiyuan 030032 China
| | - Xiaoyuan Niu
- Department of Neurology First Hospital of Shanxi Medical University Taiyuan Shanxi Province 030001 China
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Simonato D, Borchert RJ, Labeyrie MA, Fuschi M, Thibault L, Henkes H, Fiorella D, Tan BYQ, Yeo LLL, Makalanda HLD, Wong K, Bhogal P. Glycoprotein IIb/IIIa inhibitors for the neurointerventionalist. Interv Neuroradiol 2022; 28:84-91. [PMID: 33947250 PMCID: PMC8905078 DOI: 10.1177/15910199211015038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Antiplatelet therapies are commonly used in neurointerventional procedures. However, specific guidelines for their use in these settings is lacking and it can often be difficult to balance the potential risks and benefits of these medications. Considering the continued growth and adoption of neurointerventional procedures, it is crucial to understand the properties of these agents in order to use them safely. Large-scale clinical trials are still needed to clarify many of these aspects for this emerging field. However, the existing literature already provides insight into which antiplatelet drugs are of benefit to the neurointerventionalist as well as their associated risks of ischemic and hemorrhagic complications. Hence, this review focuses on the applications of GPIIb/IIIA inhibitors to neurointerventional procedures.
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Affiliation(s)
- Davide Simonato
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, UK,Institute of Radiology, University of Padova, Italy,Davide Simonato, Department of Neuroradiology, John Radcliffe Hospital, Oxford, UK.
| | - Robin J Borchert
- Department of Clinical Neurosciences, University of Cambridge, UK
| | | | - Maurizio Fuschi
- Department of Neuroradiology, Oxford University Hospital NHS Foundation Trust, UK
| | | | - Hans Henkes
- Clinic for Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University Hospital, New York, USA
| | - Benjamin YQ Tan
- Division of Neurology, National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Leonard LL Yeo
- Division of Neurology, National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Ken Wong
- Royal London Hospital, London, UK
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Kamarova M, Baig S, Patel H, Monks K, Wasay M, Ali A, Redgrave J, Majid A, Bell SM. Antiplatelet Use in Ischemic Stroke. Ann Pharmacother 2022; 56:1159-1173. [PMID: 35094598 PMCID: PMC9393649 DOI: 10.1177/10600280211073009] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: A literature review of antiplatelet agents for primary and secondary stroke
prevention, including mechanism of action, cost, and reasons for lack of
benefit. Data sources: Articles were gathered from MEDLINE, Cochrane Reviews, and PubMed databases
(1980-2021). Abstracts from scientific meetings were considered. Search
terms included ischemic stroke, aspirin, clopidogrel, dipyridamole,
ticagrelor, cilostazol, prasugrel, glycoprotein IIb/IIIa inhibitors. Study selection and data extraction: English-language original and review articles were evaluated. Guidelines from
multiple countries were reviewed. Articles were evaluated independently by 2
authors. Data synthesis: An abundance of evidence supports aspirin and clopidogrel use for secondary
stroke prevention. In the acute phase (first 21 days postinitial stroke),
these medications have higher efficacy for preventing further stroke when
combined, but long-term combination therapy is associated with higher
hemorrhage rates. Antiplatelet treatment failure is influenced by poor
adherence and genetic polymorphisms. Antiplatelet agents such as cilostazol
may provide extra benefit over clopidogrel and aspirin, in certain racial
groups, but further research in more diverse ethnic populations is
needed. Relevance to patient care and clinical practice: This review presents the data available on the use of different antiplatelet
agents poststroke. Dual therapy, recurrence after initiation of secondary
preventative therapy, and areas for future research are discussed. Conclusions: Although good evidence exists for the use of certain antiplatelet agents
postischemic stroke, there are considerable opportunities for future
research to investigate personalized therapies. These include screening
patients for platelet polymorphisms that confer antiplatelet resistance and
for randomized trials including more racially diverse populations.
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Affiliation(s)
- Marharyta Kamarova
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
| | - Sheharyar Baig
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
- Sheffield Institute for Translational
Neuroscience (SITraN), The University of Sheffield, Sheffield, UK
| | - Hamish Patel
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
| | - Kimberley Monks
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
| | - Mohammed Wasay
- Department of Neurology, The Aga Khan
University, Karachi, Pakistan
| | - Ali Ali
- Department of Medicine for the Elderly,
Royal Hallamshire Hospital, Sheffield, UK
| | - Jessica Redgrave
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
| | - Arshad Majid
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
- Sheffield Institute for Translational
Neuroscience (SITraN), The University of Sheffield, Sheffield, UK
| | - Simon M. Bell
- Department of Clinical Neurology, Royal
Hallamshire Hospital, Sheffield, UK
- Sheffield Institute for Translational
Neuroscience (SITraN), The University of Sheffield, Sheffield, UK
- Simon M. Bell, NIHR Clinical Lecturer in
Neurology, Sheffield Institute for Translational Neuroscience (SITraN), The
University of Sheffield, 385a Glossop Road, Sheffield S10 2HQ, UK.
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Minhas JS, Chithiramohan T, Wang X, Barnes SC, Clough RH, Kadicheeni M, Beishon LC, Robinson T. Oral antiplatelet therapy for acute ischaemic stroke. Cochrane Database Syst Rev 2022; 1:CD000029. [PMID: 35028933 PMCID: PMC8758582 DOI: 10.1002/14651858.cd000029.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND In people with acute ischaemic stroke, platelets become activated and can cause blood clots to form and block an artery in the brain, resulting in damage to part of the brain. Such damage gives rise to the symptoms of stroke. Antiplatelet therapy might reduce the volume of brain damaged by ischaemia and also reduce the risk of early recurrent ischaemic stroke, thereby reducing the risk of early death and improving long-term outcomes in survivors. However, antiplatelet therapy might also increase the risk of fatal or disabling intracranial haemorrhage. OBJECTIVES To assess the efficacy and safety of immediate oral antiplatelet therapy (i.e. started as soon as possible and no later than two weeks after stroke onset) in people with acute presumed ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, and two trials registers, and performed forward reference/cited reference searching in August 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing oral antiplatelet therapy (started within 14 days of the stroke) with control in people with definite or presumed ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria and assessed trial quality. For the included trials, they extracted and cross-checked the data. They assessed risk of bias of each study using the Risk of Bias 1 (RoB1) tool and overall certainty of the evidence for each outcome using the GRADE approach. MAIN RESULTS We included 11 studies involving 42,226 participants. Three new trials have been added since the last update (743 participants). As per the previous version of this review, two trials testing aspirin 160 mg to 300 mg once daily, started within 48 hours of onset, contributed 96% of the data. The risk of bias was low. The maximum follow-up was six months. With treatment, there was a decrease in death or dependency at the end of follow-up (odds ratio (OR) 0.95, 95% confidence interval (CI) 0.91 to 0.99; 7 RCTs, 42,034 participants; moderate-certainty evidence). For every 1000 people treated with aspirin, 13 people would avoid death or dependency (number needed to treat for an additional beneficial outcome 79). AUTHORS' CONCLUSIONS Antiplatelet therapy with aspirin 160 mg to 300 mg daily, given orally (or by nasogastric tube or per rectum in people who cannot swallow) and started within 48 hours of onset of presumed ischaemic stroke, significantly decreased death and dependency, and reduced the risk of early recurrent ischaemic stroke without a major risk of early haemorrhagic complications; long-term outcomes were improved.
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Affiliation(s)
- Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Sam C Barnes
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rebecca H Clough
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Meeriam Kadicheeni
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Lucy C Beishon
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Passacquale G, Sharma P, Perera D, Ferro A. Antiplatelet therapy in cardiovascular disease: current status and future directions. Br J Clin Pharmacol 2022; 88:2686-2699. [PMID: 35001413 PMCID: PMC9303765 DOI: 10.1111/bcp.15221] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022] Open
Abstract
Antiplatelet medications remain a cornerstone of therapy for atherosclerotic cardiovascular and cerebrovascular diseases. In primary prevention (patients with cardiovascular risk factors but no documented events, symptoms or angiographic disease), there is little evidence of benefit of any antiplatelet therapy, and such therapy carries the risk of excess bleeding. Where there is documented disease (secondary prevention), stable patients benefit from long-term antiplatelet monotherapy, aspirin being first choice in those with coronary heart disease and clopidogrel in those with cerebrovascular disease; moreover, recent evidence shows that low-dose rivaroxaban in combination with aspirin confers added benefit, in patients with stable cardiovascular and peripheral arterial disease. In patients with acute cerebrovascular disease, aspirin combined with clopidogrel reduces subsequent risk, while in acute coronary syndrome, dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) confers greater protection than aspirin monotherapy, with prasugrel and ticagrelor offering greater antiplatelet efficacy with faster onset of action than clopidogrel. Although greater antiplatelet efficacy is advantageous in preventing thrombotic events, this must be tempered by increased risk of bleeding which may be a particular issue in certain patient groups, as will be discussed. We will also discuss possible future approaches to personalisation of antiplatelet therapy.
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Affiliation(s)
- Gabriella Passacquale
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, Surrey, UK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
| | - Albert Ferro
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
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Adams HP, Davis PH. Antithrombotic Therapy for Treatment of Acute Ischemic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00054-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sugimori H, Mori K, Yasaka M. [Antithrombotic therapy considering risk of falls and bleeding in the elderly]. Nihon Ronen Igakkai Zasshi 2022; 59:305-311. [PMID: 36070904 DOI: 10.3143/geriatrics.59.305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Arutyunov G, Amelin A, Voznyuk I, Kulesh A, Maximova M, Mkrtchyan V, Putilina M, Sorokoumov V, Fonyakin A, Khasanova D. COMPASS study results as a foundation for new treatment approach for neurological patients. Opinion of the expert council of december 18, 2021. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:94-99. [DOI: 10.17116/jnevro202212204194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Wang Y, Meng X, Wang A, Xie X, Pan Y, Johnston SC, Li H, Bath PM, Dong Q, Xu A, Jing J, Lin J, Niu S, Wang Y, Zhao X, Li Z, Jiang Y, Li W, Liu L, Xu J, Chang L, Wang L, Zhuang X, Zhao J, Feng Y, Man H, Li G, Wang B. Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA. N Engl J Med 2021; 385:2520-2530. [PMID: 34708996 DOI: 10.1056/nejmoa2111749] [Citation(s) in RCA: 127] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Comparisons between ticagrelor and clopidogrel for the secondary prevention of stroke in CYP2C19 loss-of-function carriers have not been extensively performed. METHODS We conducted a randomized, double-blind, placebo-controlled trial at 202 centers in China involving patients with a minor ischemic stroke or transient ischemic attack (TIA) who carried CYP2C19 loss-of-function alleles. Patients were assigned within 24 hours after symptom onset, in a 1:1 ratio, to receive ticagrelor (180 mg on day 1 followed by 90 mg twice daily on days 2 through 90) and placebo clopidogrel or to receive clopidogrel (300 mg on day 1 followed by 75 mg once daily on days 2 through 90) and placebo ticagrelor; both groups received aspirin for 21 days. The primary efficacy outcome was new stroke, and the primary safety outcome was severe or moderate bleeding, both within 90 days. RESULTS A total of 11,255 patients were screened and 6412 patients were enrolled, with 3205 assigned to the ticagrelor group and 3207 to the clopidogrel group. The median age of the patients was 64.8 years, and 33.8% were women; 98.0% belonged to the Han Chinese ethnic group. Stroke occurred within 90 days in 191 patients (6.0%) in the ticagrelor group and 243 patients (7.6%) in the clopidogrel group (hazard ratio, 0.77; 95% confidence interval, 0.64 to 0.94; P = 0.008). Secondary outcomes were generally in the same direction as the primary outcome. Severe or moderate bleeding occurred in 9 patients (0.3%) in the ticagrelor group and in 11 patients (0.3%) in the clopidogrel group; any bleeding occurred in 170 patients (5.3%) and 80 patients (2.5%), respectively. CONCLUSIONS Among Chinese patients with minor ischemic stroke or TIA who were carriers of CYP2C19 loss-of-function alleles, the risk of stroke at 90 days was modestly lower with ticagrelor than with clopidogrel. The risk of severe or moderate bleeding did not differ between the two treatment groups, but ticagrelor was associated with more total bleeding events than clopidogrel. (Funded by the Ministry of Science and Technology of the People's Republic of China and others; CHANCE-2 ClinicalTrials.gov number, NCT04078737.).
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Affiliation(s)
- Yongjun Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xia Meng
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Anxin Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xuewei Xie
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuesong Pan
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - S Claiborne Johnston
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Hao Li
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Philip M Bath
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Qiang Dong
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Anding Xu
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jing Jing
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinxi Lin
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Siying Niu
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yilong Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xingquan Zhao
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Zixiao Li
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yong Jiang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Wei Li
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Liping Liu
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jie Xu
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Liguo Chang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Lihua Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xianbo Zhuang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinguo Zhao
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yefang Feng
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Honghao Man
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Guozhong Li
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Baojun Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
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Bir S, Kelley RE. Antithrombotic Therapy in the Prevention of Stroke. Biomedicines 2021; 9:1906. [PMID: 34944719 PMCID: PMC8698439 DOI: 10.3390/biomedicines9121906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 11/24/2022] Open
Abstract
OVERVIEW Ischemic stroke is a leading cause of death and disability throughout the world. Antithrombotic therapy, which includes both antiplatelet and anticoagulant agents, is a primary medication of choice for the secondary prevention of stroke. However, the choices vary with the need to incorporate evolving, newer information into the clinical scenario. There is also the need to factor in co-morbid medical conditions as well as the cost ramifications for a particular patient as well as compliance with the regimen. Pertinent Updates: In the acute setting, dual antiplatelet therapy from three weeks to up to three months has become recognized as a reasonable approach for patients with either minor stroke or transient ischemic attack or those with symptoms associated with higher-grade intracranial stenosis. This approach is favored for non-cardioembolic stroke as a cardiogenic mechanism tends to be best managed with attention to the cardiac condition as well as anticoagulant therapy. Risk stratification for recurrent stroke is important in weighing potential risk versus benefits. For example, prolonged dual antiplatelet therapy, with a combination such as aspirin and clopidogrel or aspirin and ticagrelor, tends to have negation of the potential clinical benefit of stroke prevention, over time, by the enhanced bleeding risk. Anticoagulant choices are now impacted by newer agents, initially identified as novel oral anticoagulants (NOACs), which also became associated with "non-vitamin K" agents as they are no longer considered novel. Alternatively, they are now often identified as direct oral anticoagulants (DOACs). They tend to be viewed as superior or non-inferior to warfarin with the caveat that warfarin is still viewed as the agent of choice for stroke prevention in patients with mechanical heart valves. CONCLUSION Based upon cumulative information from multiple clinical trials of secondary prevention of stroke, there is an increasing array of approaches in an effort to provide optimal management. Antithrombotic therapy, including in combination with anticoagulant therapy, continues to evolve with the general caveat that "one size does not fit all". In view of this, we desire to provide an evidence-based approach for the prevention of stroke with antithrombotic agents.
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Affiliation(s)
| | - Roger E. Kelley
- Department of Neurology, Ochsner/LSU Health Sciences Center, Shreveport, LA 71130, USA;
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Woodhouse LJ, Montgomery AA, Mant J, Davis BR, Algra A, Mas JL, Staessen JA, Thijs L, Tonkin A, Kirby A, Pocock SJ, Chalmers J, Hankey GJ, Spence JD, Sandercock P, Diener HC, Uchiyama S, Sprigg N, Bath PM. Statistical reanalysis of vascular event outcomes in primary and secondary vascular prevention trials. BMC Med Res Methodol 2021; 21:218. [PMID: 34657596 PMCID: PMC8520648 DOI: 10.1186/s12874-021-01388-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vascular prevention trials typically use dichotomous event outcomes although this may be inefficient statistically and gives no indication of event severity. We assessed whether ordinal outcomes would be more efficient and how to best analyse them. METHODS Chief investigators of vascular prevention randomised controlled trials that showed evidence of either benefit or harm, or were included in a systematic review that overall showed benefit or harm, shared individual participant data from their trials. Ordered categorical versions of vascular event outcomes (such as stroke and myocardial infarction) were analysed using 15 statistical techniques and their results then ranked, with the result with the smallest p-value given the smallest rank. Friedman and Duncan's multiple range tests were performed to assess differences between tests by comparing the average ranks for each statistical test. RESULTS Data from 35 trials (254,223 participants) were shared with the collaboration. 13 trials had more than two treatment arms, resulting in 59 comparisons. Analysis approaches (Mann Whitney U, ordinal logistic regression, multiple regression, bootstrapping) that used ordinal outcome data had a smaller average rank and therefore appeared to be more efficient statistically than those that analysed the original binary outcomes. CONCLUSIONS Ordinal vascular outcome measures appear to be more efficient statistically than binary outcomes and provide information on the severity of event. We suggest a potential role for using ordinal outcomes in vascular prevention trials.
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Affiliation(s)
- Lisa J Woodhouse
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jonathan Mant
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Barry R Davis
- The University of Texas Health Science Center at Houston, Houston, USA
| | - Ale Algra
- University Medical Center Utrecht, Utrecht, Netherlands
| | - Jean-Louis Mas
- Hopital Sainte-Anne, Université Paris-Descartes, Paris, France
| | - Jan A Staessen
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Lutgarde Thijs
- Department of Cardiovascular Sciences, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Andrew Tonkin
- Chronic Disease & Aging Unit, Monash University, Clayton, Australia
| | - Adrienne Kirby
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia
| | | | - John Chalmers
- George Institute for Global Health, Sydney, Australia
| | - Graeme J Hankey
- Department of Neurology, University of Western Australia, Crawley, Australia
| | | | - Peter Sandercock
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Nikola Sprigg
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK
| | - Philip M Bath
- Stroke, Mental Health & Clinical Neurosciences, University of Nottingham, Nottingham, UK.
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Abstract
PURPOSE OF REVIEW Antiplatelet therapy remains the standard of care in secondary stroke prevention for non-cardioembolic ischemic stroke and transient ischemic attack. We aim to examine the use of antiplatelet agents in secondary prevention through highlighting relevant clinical trials and meta-analyses as well as providing commentary regarding our practice. RECENT FINDINGS In the POINT and CHANCE trials, dual antiplatelet therapy reduced recurrent stroke compared to aspirin monotherapy. Sub-analyses of these trials suggest that genetic polymorphisms could play a role in diminishing the effectiveness of clopidogrel. Similarly, THALES demonstrated better outcomes with ticagrelor-aspirin combination therapy over aspirin monotherapy. Combination antiplatelet therapy with aspirin and the P2Y12 inhibitors, clopidogrel and ticagrelor, reduced stroke recurrence in those presenting with mild ischemic stroke or high risk TIA. Genetic polymorphisms may play a role in determining the appropriate regimen. Questions remain regarding the optimal duration of combination antiplatelet therapy for various stroke etiologies.
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Capodanno D, Angiolillo DJ. Oral antithrombotic therapy for the prevention of recurrent cerebrovascular events. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:383-391. [PMID: 34374741 DOI: 10.1093/ehjcvp/pvab062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/06/2021] [Accepted: 08/06/2021] [Indexed: 11/13/2022]
Abstract
Stroke is frequently a disabling and even life-threatening condition that has an ischemic cause in most cases. Transient ischemic attack (TIA) is a lower-risk condition that still exposes to the risk of future major cardiovascular events. The causes of stroke can be classified as cardioembolic disease, large vessel disease, small vessel disease, undetermined, or others. Cardioembolic disease and atherothrombosis of large arteries are the most common underlying processes of ischemic stroke and TIA. Therefore, antithrombotic therapy is a central strategy in the pharmacological management of these patients. However, because antithrombotic therapy provides ischemic protection at the price of increased bleeding, defining the fine balance between efficacy and safety is a clinical challenge. Numerous trials have recently defined the current indications to the use of anticoagulant and antiplatelet therapy in patients with various subtypes of ischemic stroke or TIA. In this review, we provide an updated appraisal of the currently available evidence on the use of various oral antithrombotic agents for prevention of recurrent events after an ischemic stroke or TIA.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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