Abstract 1: Dual Antiplatelet Therapy is More Effective for Multiple Acute Infarcts: Subgroup Analysis of Chance

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Yilong Wang ◽  
Jing Jing ◽  
Yongjun Wang
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Recurrent Stroke ◽  
Bleeding Event ◽  
Minor Stroke ◽  
Stroke Recurrence ◽  
Severe Bleeding ◽  
Stroke Patients ◽  
Acute Infarction ◽  
Increased Risk

Background and Purpose: TIAregistry.org project showed that TIA and minor stroke patients with multiple acute infarctions (MAIs), which represent mechanisms of embolism, are at higher risk of recurrent stroke as compared to those with none or single acute infarction (SAI). We hypothesis that patient with MAIs may be more susceptible to dual antiplatelet therapy. Methods: We compared clopidogrel plus aspirin with aspirin alone with regard to their effectiveness and safety for prevention of stroke recurrence among non-cardiac TIA and minor ischemic stroke patients with different infarction patterns (no acute infarction, SAI, or MAIs) in the imaging subgroup from the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial. The efficacy and safety outcome were stroke recurrence and moderate-to-severe bleeding event at 90 days respectively. Results: Overall, 1089 patients at 45 centers in CHANCE trial were included. The rate of recurrent stroke was 14.2%, 8.7%, and 2.0% in patients with MAIs, SAI and no infarction respectively at 90 days. Increased risk of stroke recurrence was observed in patients with MAIs (HR, 5.9; 95% CI, 2.3-15.2) and SAI (HR, 4.1; 95% CI, 1.6-10.7) (Figure A) as compared to those without infarction. The dual antiplatelet treatment was superior to aspirin alone for reducing the risk of recurrent stroke in patients with MAIs (HR 0.48; 95% CI, 0.25- 0.92; P = 0.03) but not in patients with SAI and without acute infarction with P=0.046 for interaction (Figure B-D). The effect of treatment assignment on bleeding did not vary among groups with different infarction patterns ( P >0.05 for all). Conclusions: Patients with MAIs had the highest risk for stroke recurrence among patients with different infarction patterns. Patients with MAIs may benefit the most clinically from dual antiplatelet therapy and dual antiplatelet therapy does not increase the risk of hemorrhage among any groups.

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

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

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

Prevalence of CYP2C19*2 carriers in Saudi ischemic stroke patients and the suitability of using genotyping to guide antiplatelet therapy in a university hospital setup

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Abdullah M. Al-Rubaish ◽  
Fahad A. Al-Muhanna ◽  
Abdullah M. Alshehri ◽  
Abdulla A. Alsulaiman ◽  
Majed M. Alabdulali ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Recurrent Stroke ◽  
University Hospital ◽  
Normal Allele ◽  
Stroke Patients ◽  
Stroke Event ◽  
Increased Risk ◽  
Age And Sex

Abstract Objectives To mitigate the incidence of recurrent stroke in patients, dual antiplatelet therapy comprising aspirin and clopidogrel is usually administered. Clopidogrel is a prodrug and its bioactivation is catalyzed by cytochrome P450 (CYP)2C19. The main objective of this work was to determine the prevalence of CYP2C19*2 carriers in Saudi ischemic stroke patients and assess the suitability of using genotyping to guide antiplatelet therapy in a university hospital setup. Methods This prospective (2018–2019) study was conducted on 256 patients (age 61 ± 12.5) clinically diagnosed with ischemic stroke who were genotyped using Spartan RX CYP2C19 assay. Results From the total patient group (256), upon admission, 210 patients were prescribed either aspirin, clopidogrel or dual antiplatelet therapy. Of the 27 patients with the CYP2C19*2 allele who were prescribed clopidogrel (18) or dual antiplatelet therapy (9), only 21 patients could be followed up for a period of six months post stroke event, in addition to 21 age- and sex-matched patients with the normal allele. The CYP2C19*2 allele carriers had a statistically significant increased risk of recurrent stroke compared to patients carrying the normal allele. Conclusions This study shows the suitability of using genotyping to guide antiplatelet therapy in ischemic stroke patients in a clinical setting.

Abstract 41: Prognostic Value of Perfusion MRI in Patients with Transient Ischemic Attack or Minor Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Joon Hwa Lee ◽  
Hyunjin Jo ◽  
Jihoon Cha ◽  
Woo-Keun Seo ◽  
Oh Young Bang ◽  
...  
Keyword(s):  
Cardiovascular Event ◽  
Transient Ischemic Attack ◽  
Recurrent Stroke ◽  
Perfusion Mri ◽  
Minor Stroke ◽  
Secondary Outcome ◽  
Stroke Recurrence ◽  
Composite Outcome ◽  
Stroke Patients ◽  
Ischemic Attack

Background and purpose: We aimed to investigate the role of perfusion MRI parameters (TTP: time to peak, CBF: cerebral blood flow, CBV: cerebral blood volume) as a prognostic factor for the risk of stroke recurrence or cardiovascular outcome in patients with transient ischemic attack (TIA) or minor stroke. Methods: We retrospectively reviewed TIA or minor stroke patients who underwent our stroke MRI protocol (DWI, perfusion MRI, and MRA) in a consecutively collected stroke registry. Primary outcome was nonfatal stroke recurrence and secondary outcome was cardiovascular composite outcome. Multivariate analysis was used to examine the association of perfusion MRI parameters and angiographic findings with the risk of stroke recurrence and cardiovascular event. Results: Of the 326 patients who met inclusion criteria, we identified 15(4.6%) nonfatal strokes and 25(7.7%) cardiovascular composite events during the first 1 year after the index TIA or minor stroke. The presence of regional delayed perfusion on TTP maps (p=0.002) and regional hyperperfusion on CBV maps (p<0.001) were associated with recurrent stroke. In MRA images, concomitant stenosis of the intracranial arteries and/or extracranial carotid arteries was associated with cardiovascular events (p=0.009). Using multivariate cox proportional hazard analysis, presence of regional hyperperfusion on CBV remained an independent predictor of recurrent stroke (HR 10.82, 95% CI 4.19-38.67, p<0.001) and cardiovascular event (HR 6.30, 95% CI 2.67-18.25, p<0.001). The AUC of the CBV maps was also greater than other parameters for the prediction of stroke recurrence (AUC=0.701, 95% CI 0.54-0.86) and cardiovascular composite outcome (AUC=0.628, 95% CI 0.50-0.76). Conclusions: Increased CBV on perfusion MRI, representing the hemodynamic status of postischemic hyperperfusion, could be more useful than other perfusion parameters in predicting poor prognosis of TIA or minor stroke patients.

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

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

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

scholarly journals The Acute Stroke or Transient Ischemic Attack Treated with Ticagrelor and Aspirin for Prevention of Stroke and Death (THALES) trial: Rationale and design

2019 ◽  
Vol 14 (7) ◽  
pp. 745-751 ◽  
Author(s):  
S Claiborne Johnston ◽  
Pierre Amarenco ◽  
Hans Denison ◽  
Scott R Evans ◽  
Anders Himmelmann ◽  
...  
Keyword(s):  
Cerebral Ischemia ◽  
Acute Stroke ◽  
Antiplatelet Therapy ◽  
Transient Ischemic Attack ◽  
Dual Antiplatelet Therapy ◽  
Bleeding Event ◽  
Severe Bleeding ◽  
Major Hemorrhage ◽  
Acute Cerebral Ischemia ◽  
Ischemic Attack

Rationale In patients with acute cerebral ischemia, the rate of stroke, myocardial infarction, or death during 90 days was reported to be non-significantly lower with ticagrelor compared with aspirin, with no increase in major hemorrhage. Dual antiplatelet therapy may be more effective in this setting. Aim To investigate whether ticagrelor combined with aspirin are superior to aspirin alone in preventing stroke or death in patients with non-severe, non-cardioembolic ischemic stroke or high-risk transient ischemic attack. Design The Acute Stroke or Transient Ischemic Attack Treated with Ticagrelor and Aspirin for Prevention of Stroke and Death (THALES) trial is a randomized, placebo-controlled, double-blind, event-driven study. Patients will be randomized within 24 h of onset of acute ischemic symptoms. THALES is expected to randomize 13,000 at ∼450 sites worldwide, to collect 764 primary outcome events. Study treatments are ticagrelor 180 mg loading dose on day 1, then 90 mg twice daily on days 2–30, or matching placebo. All patients will also receive open-label aspirin 300–325 mg on day 1, then 75–100 mg once daily on days 2–30. Study outcomes The primary efficacy outcome is time to the composite endpoint of stroke or death through 30-day follow-up. The primary safety outcome is time to first severe bleeding event. Discussion The THALES trial will provide important information about the benefits and risks of dual antiplatelet therapy with ticagrelor and aspirin in patients with acute cerebral ischemia in a global setting (funding: AstraZeneca). Clinical Trial Registration URL http://www.clinicaltrials.gov . Unique identifier: NCT03354429.

scholarly journals WMH and long-term outcomes in ischemic stroke

Neurology ◽  
2019 ◽  
Vol 92 (12) ◽  
pp. e1298-e1308 ◽  
Author(s):  
Marios K. Georgakis ◽  
Marco Duering ◽  
Joanna M. Wardlaw ◽  
Martin Dichgans
Keyword(s):  
Ischemic Stroke ◽  
Functional Impairment ◽  
Recurrent Stroke ◽  
Meta Analysis ◽  
Sensitivity Analyses ◽  
Stroke Recurrence ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Increased Risk

ObjectiveTo investigate the relationship between baseline white matter hyperintensities (WMH) in patients with ischemic stroke and long-term risk of dementia, functional impairment, recurrent stroke, and mortality.MethodsFollowing the Meta-analysis of Observational Studies in Epidemiology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO protocol: CRD42018092857), we systematically searched Medline and Scopus for cohort studies of ischemic stroke patients examining whether MRI- or CT-assessed WMH at baseline are associated with dementia, functional impairment, recurrent stroke, and mortality at 3 months or later poststroke. We extracted data and evaluated study quality with the Newcastle–Ottawa scale. We pooled relative risks (RR) for the presence and severity of WMH using random-effects models.ResultsWe included 104 studies with 71,298 ischemic stroke patients. Moderate/severe WMH at baseline were associated with increased risk of dementia (RR 2.17, 95% confidence interval [CI] 1.72–2.73), cognitive impairment (RR 2.29, 95% CI 1.48–3.54), functional impairment (RR 2.21, 95% CI 1.83–2.67), any recurrent stroke (RR 1.65, 95% CI 1.36–2.01), recurrent ischemic stroke (RR 1.90, 95% CI 1.26–2.88), all-cause mortality (RR 1.72, 95% CI 1.47–2.01), and cardiovascular mortality (RR 2.02, 95% CI 1.44–2.83). The associations followed dose-response patterns for WMH severity and were consistent for both MRI- and CT-defined WMH. The results remained stable in sensitivity analyses adjusting for age, stroke severity, and cardiovascular risk factors, in analyses of studies scoring high in quality, and in analyses adjusted for publication bias.ConclusionsPresence and severity of WMH are associated with substantially increased risk of dementia, functional impairment, stroke recurrence, and mortality after ischemic stroke. WMH may aid clinical prognostication and the planning of future clinical trials.

High-sensitive C-reactive protein and dual antiplatelet in intracranial arterial stenosis

Neurology ◽  
2018 ◽  
Vol 90 (6) ◽  
pp. e447-e454 ◽  
Author(s):  
Jiejie Li ◽  
Anxin Wang ◽  
Xingquan Zhao ◽  
Liping Liu ◽  
Xia Meng ◽  
...  
Keyword(s):  
High Risk ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Recurrent Stroke ◽  
Arterial Stenosis ◽  
Minor Stroke ◽  
Intracranial Arterial Stenosis ◽  
C Reactive Protein ◽  
Vascular Events ◽  
Reactive Protein

ObjectiveTo determine the relationship of high-sensitive C-reactive protein (hsCRP) and the efficacy and safety of dual antiplatelet therapy in patients with and without intracranial arterial stenosis (ICAS) in the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events (CHANCE) trial.MethodsA subgroup of 807 patients with both magnetic resonance angiography images and hsCRP measurement was analyzed. Cox proportional hazards models were used to assess the interaction of hsCRP levels with the effects of dual and single antiplatelet therapy.ResultsA total of 358 (44.4%) patients had ICAS and 449 (55.6%) did not. The proportion of patients with elevated hsCRP levels was higher in the ICAS group than in the non-ICAS group (40.2% vs 30.1%, p = 0.003). There was significant interaction between hsCRP and the 2 antiplatelet therapy groups in their effects on recurrent stroke after adjustment for confounding factors in the patients with ICAS (p = 0.012), but not in those without (p = 0.256). Compared with aspirin alone, clopidogrel plus aspirin significantly reduced the risk of recurrent stroke only in the patients with ICAS and nonelevated hsCRP levels (adjusted hazard ratio 0.27; 95% confidence interval 0.11 to 0.69; p = 0.006). Similar results were observed for composite vascular events. No significant difference in bleeding was found.ConclusionsPresence of both ICAS and nonelevated hsCRP levels may predict better response to dual antiplatelet therapy in reducing new stroke and composite vascular events in minor stroke or high-risk TIA patients. Further large-scale randomized and controlled clinical trials are needed to confirm this finding.

Abstract 213: Cerebral Microbleeds in 1278 Lacunar Stroke Patients: The Secondary Prevention of Small Subcortical Strokes (SPS3) Trial

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Ashkan Shoamanesh ◽  
Lesly A Pearce ◽  
Carlos Bazan ◽  
Luciana Catanese ◽  
Leslie A McClure ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Recurrent Stroke ◽  
Large Population ◽  
Cerebral Microbleeds ◽  
Stroke Recurrence ◽  
Blood Pressure Target ◽  
Lacunar Stroke ◽  
Stroke Patients ◽  
Increased Risk ◽  
History Of

Background: Cerebral microbleeds (CMBs) are radiographic markers of cerebral small vessel disease (CSVD) reported to independently predict recurrent stroke and mortality. However, characterization of CMBs in a large population of pure CSVD is lacking. We aimed to characterize CMBs in a well-defined population of lacunar stroke patients, and assess the relationship between CMBs and recurrent stroke and death. Methods: SPS3 was a randomized trial investigating optimal blood pressure target and antiplatelet regimen in 3020 patients with recent, symptomatic, MRI-confirmed lacunar stroke. CMBs were rated as per the Brain Observer MicroBleed Scale in all participants who had an interpretable axial T2*- GRE sequence available as part of their baseline MRI (n=1278, intra-rater reliability for + CMB 91% agreement, Kappa = 0.82). Results: CMBs were present in 30% of 1278 patients (mean age 63 y, 65% male, 75% history of hypertension). CMBs were lobar in 21%, deep in 44%, and mixed in 35% of cases. Of patients with CMBs, most (57%) had 1-2 CMBs, 31% had 3-10, and 12% >10. Male gender (OR 1.7, 95% CI 1.3-2.3), history of hypertension (1.6, 1.2-2.3), increased systolic blood pressure (1.2 per 20 mmHg, 1.1-1.4), non-diabetic (1.4, 1.1-1.9), multiple lacunar infarcts (1.9, 1.5-2.5) and moderate (1.7, 1.2-2.3) or severe (4.2, 3.0-5.9) white matter hyperintensities on MRI were independently associated with the odds of having CMBs in multivariable logistic regression. During a mean follow-up of 3.3 y, overall stroke recurrence was 2.5% per patient-y. In comparison to patients without CMBs, those with CMBs had a two-fold increased risk of stroke (HR 2.1, 1.4-3.1), after adjusting for assigned treatments and risk factors, whereas those with >10 CMBs had a four-fold increased risk (HR 4.0, 1.8-8.7). CMBs were not a risk factor for death (HR 1.2, 0.8-2.0). There were no interactions between CMBs and treatment assignments. Conclusions: In this largest reported cohort of lacunar stroke investigating CMBs, CMBs were highly prevalent and an independent predictor of stroke recurrence. Accordingly, patients with lacunar stroke and CMBs likely represent a more aggressive form of CSVD in need of efficacious therapeutic strategies. Further research is warranted in this field.

scholarly journals Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline

BMJ ◽  
2018 ◽  
pp. k5130 ◽  
Author(s):  
Kameshwar Prasad ◽  
Reed Siemieniuk ◽  
Qiukui Hao ◽  
Gordon Guyatt ◽  
Martin O’Donnell ◽  
...  
Keyword(s):  
High Risk ◽  
Ischaemic Stroke ◽  
Antiplatelet Therapy ◽  
Transient Ischaemic Attack ◽  
Dual Antiplatelet Therapy ◽  
Recurrent Stroke ◽  
Minor Stroke ◽  
Strong Recommendation ◽  
Ischaemic Attack

What is the role of dual antiplatelet therapy after high risk transient ischaemic attack or minor stroke? Specifically, does dual antiplatelet therapy with a combination of aspirin and clopidogrel lead to a greater reduction in recurrent stroke and death over the use of aspirin alone when given in the first 24 hours after a high risk transient ischaemic attack or minor ischaemic stroke? An expert panel produced a strong recommendation for initiating dual antiplatelet therapy within 24 hours of the onset of symptoms, and for continuing it for 10-21 days. Current practice is typically to use a single drug

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