High prevalence of previous antiplatelet drug use in patients with new or recurrent ischemic stroke: Buffalo metropolitan area and Erie County stroke study

Impact of prior antiplatelet therapy on safety and efficacy of alteplase in acute ischemic stroke: a systematic review and meta-analysis

BACKGROUND

Intravenous thrombolysis (IVT), utilizing the clot-dissolving medications alteplase (rt-PA) or tenecteplase (TNK), is the cornerstone in acute ischemic stroke (AIS) emergency intervention. However, the impact of prior antiplatelet therapy (APT) on post-IVT outcomes when utilizing alteplase remains controversial. We conducted a systematic review and meta-analysis to evaluate the effect of prior APT on the outcomes after using alteplase in AIS patients.

METHODS

We conducted a systematic review and meta-analysis synthesizing studies, which were retrieved by systematically searching PubMed, Web of Science, SCOPUS, and Cochrane through June 30, 2024. We used the R language V. 4.3. to pool dichotomous data using odds ratio (OR) with a 95% confidence interval (CI).

PROSPERO ID

CRD42024495393.

RESULTS

Thirty studies were included in our analysis, with 436,232 patients. Prior APT was significantly associated with increased odds of symptomatic intracranial hemorrhage (sICH) (OR, 1.78; 95%CI [1.48, 2.13]; P < 0.01), any ICH (OR, 1.44; 95%CI [1.16, 1.78]; P < 0.01), mortality (OR, 1.39; 95%CI [1.23, 1.58]; P < 0.01), and poor functional outcomes (modified Rankin Scale score of 3-6 [mRS 3-6]) (OR, 1.81; 95%CI [1.03, 3.19]; P = 0.04). Additionally, prior APT significantly reduced the odds of good functional outcome [mRS 0-2] (OR, 0.85; 95%CI [0.74, 0.97]; P = 0.02).

CONCLUSION

Prior APT increased hemorrhagic complications, mortality, and poor functional outcome, while reducing the odds of good functional outcome after IV alteplase. Future research should focus on identifying adjunctive agents that may decrease hemorrhagic complications and investigate the impact of various APT regimens and alternative thrombolytics beyond alteplase in this specific population.

Impact of prior antiplatelet therapy on outcomes of acute ischemic stroke undergoing endovascular treatment: A systematic review and meta-analysis

It is unclear how prior antiplatelet (APT) therapy affects outcomes of acute ischemic stroke (AIS) undergoing endovascular treatment. This review pooled data from the literature to compare outcomes of AIS between prior APT users vs non-users. PubMed, Embase, CENTRAL, and Scopus for studies were searched for studies comparing outcomes of AIS between APT users vs non-users up to 30th May 2023. Ten studies were included comparing 2648 APT users with 5076 non-users. Meta-analysis failed to demonstrate any statistically significant difference in symptomatic intracranial hemorrhage (sICH) but there was a tendency of higher mortality rates in prior APT users vs non-users. Although patients with prior APT therapy had significantly higher rates of successful recanalization as compared to patients with no prior APT treatment, meta-analysis showed significantly lower odds of functional independence amongst APT users vs non-users (OR: 0.77 95% CI: 0.68, 0.87 I2 = 22%). However, pooled analysis of adjusted data with fewer studies showed that there was no difference in sICH (OR: 1.04 95% CI: 0.78, 1.39 I2 = 0%), mortality (OR: 0.89 95% CI: 0.47, 1.68 I2 = 68%), successful recanalization (OR: 1.34 95% CI: 0.96, 1.88 I2 = 54%), and functional independence (OR: 0.96 95% CI: 0.81, 1.14 I2 = 0%) between APT users and non-users. Analysis of crude data indicates that prior APT therapy may improve successful recanalization without increasing sICH rates in AIS patients treated with endovascular therapy. However, there was an adverse effect of APT therapy on 3-month functional and survival outcomes. After adjustment of confounders, there was no difference in the odds of sICH, mortality, successful recanalization, and functional independence between APT users vs non-users.

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

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

Antiplatelet therapy increases symptomatic ICH risk after thrombolysis and thrombectomy

BACKGROUND AND PURPOSE

The influence of chronic treatment by antiplatelet drug (APD) at stroke onset on the outcomes of patients with acute ischemic stroke (AIS) treated with combined intravenous thrombolysis (IVT) and endovascular therapy (EVT) is unclear. We investigated whether prior APD use influences the risk of symptomatic intracranial hemorrhage (sICH) and functional outcome in AIS patients treated with combined reperfusion therapy.

METHODS

A single-center retrospective analysis of AIS patients with proximal intracranial occlusion who underwent IVT and EVT between January 2015 and May 2017. The main outcomes were the incidence of sICH using the Heidelberg Bleeding Classification and patients' functional status at 90 days, as defined by the modified Rankin scale (mRS). Outcomes were evaluated according to daily exposure to APD, and associations were assessed using multivariate logistic regression analysis.

RESULTS

This study included 204 patients: 71 (34.8%) were taking APD before AIS. Patients with chronic treatment by APD at stroke onset had a higher rate of sICH (26.7% vs. 3.7%; p< .001) and worse functional outcome (mRS >2) at 90 days (69% vs. 36.8%; p < .001). Prior APD use was associated with an increased likelihood of sICH (OR 9.8; 95%CI [3.6-31.3], p < .05) and of functional dependence at 90 days (OR 5.72; 95%CI [2.09-1.72], p < .001), independent of confounders on multivariate analysis.

CONCLUSIONS

Chronic treatment by APD at stroke onset in AIS patients with proximal intracranial occlusion treated using IVT and EVT increases the risk of sICH and worsens the functional prognosis. Further investigation to refine acute revascularization strategies in this population might be required.

Impact of Prior Antiplatelet Therapy on Outcomes After Endovascular Therapy for Acute Stroke: Endovascular Treatment in Ischemic Stroke Registry Results

BACKGROUND AND PURPOSE

The influence of prior antiplatelet therapy (APT) uses on the outcomes of patients with acute ischemic stroke treated with endovascular therapy is unclear. We compared procedural and clinical outcomes of endovascular therapy in patients on APT or not before stroke onset.

METHODS

We analyzed 2 groups from the ongoing prospective multicenter Endovascular Treatment in Ischemic Stroke registry in France: patients on prior APT (APT+) and patients without prior APT (APT-) treated by endovascular therapy, with and without intravenous thrombolysis. Multilevel mixed-effects logistic models including center as random effect were used to compare angiographic (rates of reperfusion at the end of procedure, procedural complications) and clinical (favorable and excellent outcome, 90-day all-cause mortality, and hemorrhagic complications) outcomes according to APT subgroups. Comparisons were adjusted for prespecified confounders (age, admission National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, intravenous thrombolysis, and time from onset to puncture), as well as for meaningful baseline between-group differences.

RESULTS

A total of 2939 patients were analyzed, of whom 877 (29.8%) were on prior APT. Patients with prior APT were older, had more frequent vascular risk factors, cardioembolic stroke mechanism, and prestroke disability. Rates of complete reperfusion (37.9% in the APT- group versus 42.7 % in the APT+ group; aOR, 1.09 [95% CI, 0.88-1.34]; P=0.41) and periprocedural complication (16.9% versus 13.3%; aOR, 0.90 [95% CI, 0.7-1.2]; P=0.66) did not differ between the two groups. Symptomatic intracerebral hemorrhage (aOR, 0.93 [95% CI, 0.63-1.37]; P=0.73), 3 months favorable clinical outcome (modified Rankin Scale score of 0-2; aOR, 0.98 [95% CI, 0.77-1.25]; P=0.89), and mortality (aOR, 0.95 [95% CI, 0.72-1.26]; P=0.76) at 90 days did not differ between the groups.

CONCLUSIONS

Prior APT does not influence angiographic and functional outcomes following endovascular therapy and should not be taken into account for acute revascularization strategies.

Prevalence and Effect of Cerebral Small Vessel Disease in Stroke Patients With Aspirin Treatment Failure-A Hospital-Based Stroke Secondary Prevention Registry

Background: Breakthrough strokes during treatment with aspirin, termed clinical aspirin treatment failure (ATF), is common in clinical practice. The burden of cerebral small vessel disease (SVD) is associated with an increased recurrent ischemic stroke risk. However, the association between SVD and ATF remains unclear. This study investigated the prevalence and clinical characteristics of SVD in stroke patients with ATF.

Methods: Data from a prospective, and multicenter stroke with ATF registry established in 2018 in Taiwan were used, and 300 patients who developed ischemic stroke concurrent with regular use of aspirin were enrolled. White matter lesions (WMLs) and cerebral microbleeds (CMBs) were identified using the Fazekas scale and Microbleed Anatomical Rating Scale, respectively. Demographic data, cardiovascular comorbidities, and index stroke characteristics of patients with different WML and CMB severities were compared. Logistic regression analyses were performed to explore the factors independently associated with outcomes after ATF.

Results: The mean patient age was 69.5 ± 11.8 years, and 70.0% of patients were men. Among all patients, periventricular WML (PVWML), deep WML (DWML), and CMB prevalence was 93.3, 90.0, and 52.5%, respectively. Furthermore, 46.0% of the index strokes were small vessel occlusions. Severe PVWMLs and DWMLs were significantly associated with high CMB burdens. Patients with moderate-to-severe PVWMLs and DWMLs were significantly older and had higher cardiovascular comorbidity prevalence than did patients with no or mild WMLs. Moreover, patients with favorable outcomes exhibited significantly low prevalence of severe PVWMLs (p = 0.001) and DWMLs (p = 0.001). After logistic regression was applied, severe WMLs predicted less favorable outcomes independently, compared with those with no to moderate PVWMLs and DWMLs [odds ratio (OR), 0.47; 95% confidence interval (CI), 0.25–0.87 for severe PVWMLs; OR, 0.40; 95% CI, 0.21–0.79 for severe DWMLs].

Conclusions: SVD is common in stroke patients with ATF. PVWMLs and DWMLs are independently associated with functional outcomes in stroke patients with ATF. The burden of SVD should be considered in future antiplatelet strategies for stroke patients after ATF.

A score to predict one-year risk of recurrence after acute ischemic stroke

BACKGROUND

An acute ischemic stroke carries a substantial risk of further recurrences. We aimed at developing and validating a prognostic tool to predict one-year stroke recurrence after acute ischemic stroke.

METHODS

An integer score was derived by Cox regression analysis on a hospital-referred cohort of 3246 acute ischemic stroke patients from Switzerland, and tested for external validity in three similar independent cohorts from Athens (n = 2495), Milan (n = 1279), and Helsinki (n = 714) by means of calibration and discrimination.

RESULTS

In the derivation cohort, the recurrence rate was 7% (n = 228/3246). We developed a nine-point score comprising: previous stroke or transient ischemic attack (1-point), stroke mechanism (small vessel disease and unknown mechanism: 0-points; rare stroke mechanism: 3-points; other mechanisms: 1-point), pre-stroke antiplatelets (1-point), active malignancy (2-points), chronic cerebrovascular lesions on imaging (1-point) and absence of early ischemic changes on first imaging (1-point). In the derivation cohort, the one-year risk of re-stroke was 3.0% (95%CI 1.9-4.1) in 932 (29%) patients with a score 0-1, 7.2% (6.1-8.3) in 2038 (63%) with a score 2-4, and 19.2% (14.6-23.9) in 276 (8%) with a score ≥ 5. The score calibrated well in the Athens (recurrences = 208/2495), but not in the Helsinki (recurrences = 15/714) or Milan (recurrences = 65/1279) cohorts. The AUC was 0.67 in the derivation cohort, and 0.56, 0.70, and 0.63 in the Athens, Helsinki, and Milan cohorts, respectively.

CONCLUSION

We developed a score to predict one-year stroke recurrence risk in patients with acute ischemic stroke. Since the score was not completely validated when applied to external datasets where it displayed poor to fair calibration and discrimination, additional efforts are required to ameliorate our accuracy for predicting stroke recurrence, by better refining this prognostic tool or developing new ones. Clinical and radiological markers of established cerebrovascular disease and stroke etiology were better predictors than the usual demographic vascular risk factors.