DAPT Tied to sICH Risk in Patients With Ischemic Stroke Who Receive Thrombolysis

Among patients with ischemic stroke who receive thrombolysis, prestroke dual antiplatelet therapy (DAPT) is associated with a significantly higher risk for symptomatic intracerebral hemorrhage (sICH), although the absolute risk is small, according to study results published in JAMA Neurology.

Researchers conducted a cohort study using data from the American Heart Association and American Stroke Association Get With The Guidelines-Stroke (GWTG-Stroke) registry between January 2013 and December 2021 to determine whether prestroke antiplatelet therapy is associated with a heightened risk for sICH following treatment with intravenous alteplase (IV-tPA).

Patients hospitalized with acute ischemic stroke who received IV-tPA were eligible for inclusion. Single antiplatelet therapy exposure was defined as aspirin, clopidogrel, prasugrel, or ticagrelor monotherapy, whereas DAPT was defined as aspirin-clopidogrel, aspirin-ticagrelor, or aspirin-prasugrel polytherapy.

The primary outcome was sICH within 36 hours of IV-tPA administration.

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Future studies are needed to elucidate the sICH risk associated with use of prestroke antiplatelet medications and thrombolysis in the era of increasing tenecteplase usage.

To investigate the association between prestroke antiplatelet exposure and outcomes, logistic regression analyses were used.

A total of 321,819 patients (mean age, 68.6; women, 51.1%; White, 68.5%) were included in the analysis, 182,344 (56.7%) of whom did not use antiplatelet therapy, 117,670 (36.5%) of whom used single antiplatelet therapy, and 21,805 (6.8%) of whom used dual antiplatelet therapy before IV alteplase.

The rates of developing sICH were 2.9%, 3.8%, and 4.1% in the no antiplatelet, single antiplatelet, and DAPT exposure groups, respectively (P <.001).

In adjusted analyses following propensity score subclassification, both prestroke single (odds ratio [OR], 1.13; 95% CI, 1.07-1.19; P <.001) and DAPT (OR, 1.28; 95% CI, 1.14-1.42; P <.001) exposure were associated with an increased risk for sICH vs no antiplatelet therapy exposure among patients with acute ischemic stroke who received IV-tPA.

There was an absolute risk increase of sICH of 0.9% and 1.2% in the single and DAPT exposure groups, respectively, vs the no antiplatelet therapy exposure group.

Rates of in-hospital mortality and life-threatening systemic hemorrhage were greater in the single (5%) and DAPT (5%) exposure groups vs the no antiplatelet therapy exposure group (4%; P <.001).

Similarly, rates of functional independence were significantly higher in the no antiplatelet therapy exposure group vs the single and DAPT exposure groups. Following propensity score subclassification and adjustment for covariates, patients with single (OR, 0.92; 95% CI, 0.90-0.95; P <.001) and DAPT (OR, 0.94; 95% CI, 0.88-0.98; P =.01) exposure vs no antiplatelet therapy exposure were less likely to have functional independence at discharge (modified Rankin scale score, ≤2).

A slight associated increase was found in in-hospital mortality in patients with DAPT vs single (OR, 1.10; 95% CI, 1.02-1.19; P =.007) and no (OR, 1.10; 95% CI, 1.00-1.21; P =.045) antiplatelet therapy exposure, but not between the single and no antiplatelet therapy exposure groups.

Study limitations included the retrospective and observational study design, imprecise

data regarding the time at which patients last took their antiplatelet medication, and varying definitions used for clinical deterioration across practices.

“Future studies are needed to elucidate the sICH risk associated with use of prestroke antiplatelet medications and thrombolysis in the era of increasing tenecteplase usage,” the researchers concluded.