Safety and efficacy of low-dose rt-PA with tirofiban to treat acute non-cardiogenic stroke: a single-center randomized controlled study

Efficacy and safety of intravenous tirofiban combined with reperfusion therapy versus reperfusion therapy alone in acute ischemic stroke: a meta-analysis of randomized controlled trials

Several studies have shown an additional benefit of tirofiban administration in patients with acute ischemic stroke (AIS) who underwent reperfusion therapy. According to the last revised guidelines, the efficacy of tirofiban in treating AIS is not well-established. Therefore, we performed a meta-analysis to assess the efficacy and safety of reperfusion therapy with tirofiban compared to reperfusion therapy alone in treating AIS. We systematically searched PubMed, Embase, and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) reporting the use of tirofiban combined with reperfusion therapy in AIS patients within 72 h after the onset of symptoms with 90 days minimum follow-up. We employed risk ratio (RR) and Mean Differences (MD) with 95% confidence intervals (CIs) as the measure of effect size using a random-effects model. We included seven RCTs comprising 1607 patients, of whom 815 (50.7%) received tirofiban combined with reperfusion therapy and 792 (49.3%) received reperfusion therapy alone (no-tirofiban). The addition of tirofiban to the reperfusion therapy resulted in a higher rate of favorable outcomes (RR 1.25; 95% CI 1.11-1.40; p < 0.001) with less functional disability (RR 0.72; 95% CI 0.53-0.98; p < 0.05). The administration of tirofiban significantly improved the National Institutes of Health Stroke Scale (NIHSS) after seven days (MD - 2.27; 95% CI - 4.32 to - 0.22; p = 0.03). A similar rate of successful revascularization was observed between groups (RR 1.18; 95% CI 0.97-1.45; p = 0.09). Tirofiban did not increase the risk of symptomatic intracranial hemorrhage (sICH) (RR 1.47; 95% CI 0.98-2.19; p = 0.06), but increase the risk of any intracranial hemorrhage (ICH), particularly in the endovascular thrombectomy (EVT) subgroup analysis (RR 1.25; 95% CI 1.03-1.51; p = 0.02). Mortality rates were similar between groups RR 1.05; 95% CI 0.80-1.38; p = 0.72). The addition of tirofiban to reperfusion therapy was associated with improved functional outcomes, without a significant increase in ICH. NIHSS after seven days of stroke onset was significantly improved by tirofiban. There was an increase in any ICH events, particularly in EVT patients. Mortality was not significantly altered by tirofiban.

Advancing stroke safety and efficacy through early tirofiban administration after intravenous thrombolysis: The multicenter, randomized, placebo-controlled, double-blind ASSET IT trial protocol

BACKGROUND

Intravenous thrombolysis (IVT) is the cornerstone treatment for the acute ischemic stroke (AIS) within 4.5 h after onset. Current guidelines recommend administering antiplatelet medications 24 h after IVT. However, vascular reocclusion is a common occurrence after IVT. Tirofiban, a platelet glycoprotein IIb/IIIa antagonist, can help deter macrovascular reocclusion, prevent microvascular thrombosis, and enhance cerebral blood flow.

OBJECTIVE

This trial aims to assess whether early administration of tirofiban can improve clinical outcomes in patients with AIS who received IVT.

METHODS AND DESIGN

The Advancing Stroke Safety and Efficacy through Early Tirofiban Administration after Intravenous Thrombolysis (ASSET IT) Trial is an investigator-initiated, randomized, placebo-controlled, double-blind, multicenter study. Up to 832 eligible patients will be consecutively randomized in a 1:1 ratio to receive either intravenous tirofiban or placebo over a period of 2 years across 38 stroke centers in China.

OUTCOMES

The primary endpoint is excellent functional status at day 90, defined as a modified Rankin Score of 0-1. Primary safety endpoints include symptomatic intracerebral hemorrhage at 24 h and mortality at 90 days.

TRIAL REGISTRY NUMBER

NCT06134622 (clinicaltrials.gov).

Efficacy and safety of tirofiban plus recombinant tissue plasminogen activator versus recombinant tissue plasminogen activator alone in acute ischemic stroke patients: a meta-analysis

OBJECTIVE

Tirofiban plus recombinant tissue plasminogen activator (rtPA) shows good efficacy and safety in treating acute ischemic stroke (AIS) patients, but there is a lack of comprehensive assessment. This meta-analysis aimed to compare the efficacy and safety of rtPA plus tirofiban with rtPA alone in AIS patients.

METHODS

This meta-analysis retrieved studies comparing rtPA intravenous thrombolysis followed by tirofiban (rtPA+T group) versus rtPA intravenous thrombolysis alone (rtPA group) for AIS patients in Excerpt Medica Database, Web of Science, Cochrane, PubMed, China National Knowledge Infrastructure, Wanfang, and SinoMed until March 2024.

RESULTS

Twenty studies with 2048 AIS patients were enrolled in this meta-analysis. National Institute of Health stroke scale (NIHSS) score after treatment was lower in the rtPA+T group than the rtPA group [standardized mean differences (SMD)=-1.41; 95 % confidence interval (CI)=-1.83, -0.98; P<0.001]. The proportion of AIS patients achieving a favorable functional outcome (modified Rankin Scale score ≤2) was increased in the rtPA+T group versus the rtPA group [relative risk (RR)=1.13; 95 % CI=1.05, 1.21; P=0.001]. The incidence of re-occlusion was lower in the rtPA+T group than in the rtPA group (RR=0.24; 95 % CI=0.10, 0.59; P=0.002), but the incidence of intracranial hemorrhage (ICH) (RR=0.85; 95 % CI=0.51, 1.43), symptomatic ICH (RR=1.10; 95 % CI=0.43, 2.84), and mortality (RR=1.39; 95 % CI=0.53, 3.65) was not different between the two groups (all P>0.05). The stability assessed by sensitivity analysis was good, and no publication bias was found.

CONCLUSION

rtPA plus tirofiban achieves superior efficacy with comparable safety profiles compared to rtPA alone in AIS patients.

Efficacy and safety of tirofiban in acute ischemic stroke patients with ideal reperfusion: A cohort study of LAA and CE subgroups

BACKGROUND AND OBJECTIVES

Despite achieving ideal reperfusion (eTICI = 3) through endovascular treatment (EVT), some acute ischemic stroke (AIS) patients still experience poor outcomes. This study aims to evaluate the efficacy and safety of tirofiban in AIS patients with ideal reperfusion, focusing on its effects in large artery atherosclerosis (LAA) and cardioembolic (CE) stroke.

METHODS

A total of 474 AIS patients from the RESCUE-BT database were included. Patients were assigned to either the tirofiban or placebo group based on the treatment received. The primary outcome was favorable functional recovery at 90 days (mRS ≤2), and safety outcomes included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. Multivariable logistic regression was used to adjust for confounders, and subgroup and interaction analyses assessed tirofiban's efficacy in LAA and CE populations.

RESULTS

In the overall population that achieved ideal reperfusion, Tirofiban did not improve clinical outcomes and did not increase the risk of mortality or incidence of sICH (p > 0.05). However, subgroup analysis indicated potential clinical benefits for patients with higher NIHSS scores in the LAA group, especially in the subgroup with NIHSS scores >13 (adjusted OR 4.671, 95% CI [1.545, 14.122]). No significant differences were found in the CE group.

CONCLUSIONS

Tirofiban showed potential benefits for LAA patients with ideal reperfusion, especially those with NIHSS scores above 13. Careful patient selection is recommended.

Intravenous Thrombolysis Plus Tirofiban in Patients with Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

Acute ischemic stroke is a cerebrovascular disease associated with high disability and mortality. Tirofiban, a platelet glycoprotein IIb/IIIa receptor antagonist, is used in conjunction with IV thrombolysis for bridging therapy, but its effectiveness and safety compared with IV thrombolysis alone in patients with stroke are not well-established.

OBJECTIVE

The aim was to conduct a systematic review and meta-analysis to determine whether tirofiban increased the risk of poor outcomes and mortality in patients with stroke and accepted IV thrombolysis within the time window, or whether it can improve functional prognosis in follow-up.

METHODS

PubMed, EMBASE, Cochrane Library, and Web of Science were searched for randomized controlled trials and observational studies from inception to June 15, 2023. Trials reporting the effectiveness and safety of tirofiban bridging after IV thrombolysis compared with thrombolysis only in patients with acute ischemic stroke were included.

RESULTS

Two randomized controlled trials and 5 observational studies with 771 participants were included. Tirofiban plus IV thrombolysis significantly favored improved neurologic function based on both modified Rankin Scale 0-2 (risk ratio [RR] 1.38; p < 0.001) and 0-1 (RR 1.54; p < 0.001) at month 3. There was no significant difference in 3-month mortality risk, symptomatic intracranial hemorrhage on the seventh day, and systemic bleeding between the 2 groups (RR 1.11; p = 0.780; RR 0.68; p = 0.670; RR 1.97; p = 0.510).

CONCLUSIONS

Tirofiban plus intravenous thrombolysis was associated with better functional outcomes, but not symptomatic intracranial hemorrhage, systemic bleedings, or mortality among patients with acute ischemic stroke compared with IV thrombolysis only. Further studies should focus on its safety profile and application to target patients.

Platelet glycoprotein IIb/IIIa antagonists in ischemic stroke patients without endovascular therapy: A meta-analysis

Platelet glycoprotein (GP) IIb/IIIa antagonists have been employed in selective patients after endovascular therapy (EVT) for acute ischemic stroke (AIS), yet application in patients without EVT is debated. This meta-analysis of randomized controlled studies on AIS patients without EVT assessed the effectiveness and safety of platelet GP IIb/IIIa antagonists compared with traditional antiplatelet or thrombolysis therapy. Articles were retrieved from databases, including PubMed, Web of Science, EMBASE, and Cochrane. The risk of bias and certainty level of evidence were assessed. Fifteen studies were included. GP IIb/IIIa antagonists increased the proportion of patients with modified Rankin Scale (mRS) 0-1 (odd ratio [OR] 1.37, 95% confidence interval [CI] 1.04-1.81, p = 0.03), mRS 0-2 (OR 1.27, 95% CI 1.12-1.46, p = 0.0004), and Barthel Index (BI) 95-100 (OR 1.25, p = 0.005); decreased the proportion of stroke progression within 5 days (OR 0.66, p = 0.006); and lowered the mean mRS score at 90 days (mean difference [MD] -0.43, p = 0.002) and the National Institute of Health stroke scale score at 7 days (MD -1.64, p < 0.00001) compared with conventional treatment. Proportions of stroke recurrence within 90 days (OR 1.20, p = 0.60), any intracranial hemorrhage (aICH) (OR 1.20, p = 0.12), symptomatic intracranial hemorrhage (sICH) (OR 0.91, p = 0.88), and death (OR 0.87, p = 0.25) had no statistical difference between both groups. This meta-analysis finds that compared with traditional antiplatelet or thrombolysis therapy, GP IIb/IIIa antagonists administered within 24-96 h of ischemic stroke onset significantly improve functional prognosis of patients with AIS not receiving EVT, as indicated by mRS and BI at 90 days, and do not increase the incidence of aICH, sICH, and death.

Intravenous thrombolysis plus tirofiban versus tirofiban alone in Caucasian patients with acute anterior choroidal or paramedian pontine infarction

BACKGROUND

Tirofiban has been shown to be superior to aspirin in achieving functional independence at 3 months for acute ischemic stroke of atheromatous or microatheromatous origin. As intravenous thrombolysis (IVT) has previously been shown to be nonsuperior to aspirin in achieving functional independence at 3 months for anterior choroidal or paramedian pontine infarction (ACI/PPI), we aimed to compare the outcomes of Caucasian patients receiving IVT plus tirofiban (IVT + T) with those receiving tirofiban alone for acute ACI/PPI.

METHODS

A retrospective study was conducted in patients aged ≥ 18 years with ACI/PPI treated in our stroke unit between December 1, 2020, and April 30, 2023, who received therapeutic intervention within 9 hours of symptom onset or after awakening with stroke symptoms. Modified Rankin Scale (mRS) ≤ 1 at 3 months was the primary endpoint. Secondary endpoints were National Institutes of Health Stroke Scale (NIHSS) ≤ 2 at day 7 or discharge and post-procedural neurological deterioration (PPND) within 72 hours. Symptomatic intracranial hemorrhage (SICH) and major systemic bleeding (MSB) were the safety measures of the study.

RESULTS

A total of 24 patients were enrolled in the tirofiban group and 43 patients in the IVT + T group. Compared to tirofiban alone, IVT + T was associated with a higher probability of achieving mRS ≤1 at 3 months (adjusted odds ratio [aOR], 8.79; 95% confidence interval [CI], 2.06-37.52; P = 0.003) and National Institutes of Health Stroke Scale ≤2 at day 7 or discharge (aOR, 3.70; 95% CI, 1.05-12.99; P = 0.041). No significant difference was seen between the two groups in preventing postprocedural neurological deterioration. One case of SICH and two cases of MSB occurred in the IVT + T group and no cases in the tirofiban group. One case of inhospital mortality was recorded in the IVT + T group.

CONCLUSIONS

Our results showed that IVT + T may be safe and effective in Caucasian patients with acute ACI/PPI.

Early tirofiban administration after intravenous thrombolysis in acute ischemic stroke (ADVENT): Study protocol of a multicenter, randomized, double-blind, placebo-controlled clinical trial

BACKGROUND

Nearly half of patients with acute ischemic stroke who undergo intravenous thrombolysis (IVT) fail to achieve excellent functional outcomes. Early administration of tirofiban after IVT may improve patient outcomes.

OBJECTIVE

To evaluate the efficacy and safety of early tirofiban administration after intravenous tenecteplase in patients with acute ischemic stroke.

METHODS AND DESIGN

The ADVENT trial is a multicenter, randomized, parallel-controlled, double-blind clinical trial. A total of 1084 patients undergoing IVT without subsequent endovascular treatment will be recruited from multiple hospitals in China. Subjects will be randomized in a 1:1 ratio to receive tirofiban or placebo, which will be infused within 6 h after IVT until 24 h after IVT, at 0.4 μg/kg/min for 30 min and then at 0.1 μg/kg/min. The primary efficacy outcome is the proportion of patients with excellent functional outcomes (modified Rankin Scale (mRS) ⩽ 1) at 90 days. Secondary outcomes include the proportion of patients with favorable functional outcomes (mRS ⩽ 2) at 90 days and neurological functional assessments evaluated during hospitalization. Symptomatic intracranial hemorrhage will be the primary safety outcome. Mortality and other adverse events will be recorded.

DISCUSSION

This pivotal trial will provide important data on the early administration of antiplatelet therapy after IVT and may promote progress in treatment standards.

TRIAL REGISTRY

ClinicalTrials.gov (NCT06045156).