Risks and Benefits Associated With Prestroke Antiplatelet Therapy Among Patients With Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator.
Abstract
Intravenous tissue plasminogen activator (tPA) is known to improve outcomes in ischemic
stroke; however, many patients may have been receiving antiplatelet therapy before
acute ischemic stroke and could face an increased risk for bleeding when treated with
tPA.To assess the risks and benefits associated with prestroke antiplatelet therapy
among patients with ischemic stroke who receive intravenous tPA.This observational
study used data from the American Heart Association and American Stroke Association
Get With the Guidelines-Stroke registry, which included 85 072 adult patients with
ischemic stroke who received intravenous tPA in 1545 registry hospitals from January
1, 2009, through March 31, 2015. Data were analyzed during the same period.Prestroke
antiplatelet therapy before tPA administration for acute ischemic stroke.Symptomatic
intracranial hemorrhage (sICH), in-hospital mortality, discharge ambulatory status,
and modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]).Of the 85 072
registry patients, 38 844 (45.7%) were receiving antiplatelet therapy before admission;
46 228 patients (54.3%) were not. Patients receiving antiplatelet therapy were older
(median [25th-75th percentile] age, 76 [65-84] vs 68 [56-80] years) and had a higher
prevalence of cardiovascular risk factors. The unadjusted rate of sICH was higher
in patients receiving antiplatelet therapy (5.0% vs 3.7%). After risk adjustment,
prior use of antiplatelet agents remained associated with higher odds of sICH compared
with no use (adjusted odds ratio [AOR], 1.18 [95% CI, 1.10-1.28]; absolute difference,
+0.68% [95% CI, 0.36%-1.01%]; number needed to harm [NNH], 147). Among patients enrolled
on October 1, 2012, or later, the highest odds (95% CIs) of sICH were found in 15
116 patients receiving aspirin alone (AOR, 1.19 [1.06- 1.34]; absolute difference
[95% CI], +0.68% [0.21%-1.20%]; NNH, 147) and 2397 patients receiving dual antiplatelet
treatment of aspirin and clopidogrel (AOR, 1.47 [1.16-1.86]; absolute difference,
+1.67% [0.58%-3.00%]; NNH, 60). The risk for in-hospital mortality was similar between
those who were and were not receiving antiplatelet therapy after adjustment (8.0%
vs 6.6%; AOR, 1.00 [0.94-1.06]; nonsignificant absolute difference, -0.01% [-0.37%
to 0.36%]). However, patients receiving antiplatelet therapy had a greater risk-adjusted
likelihood of independent ambulation (42.1% vs 46.6%; AOR, 1.13 [1.08-1.17]; absolute
difference, +2.23% [1.55%-2.92%]; number needed to treat, 43) and better functional
outcomes (modified Rankin Scale score, 0-1) at discharge (24.1% vs 27.8%; AOR, 1.14;
1.07-1.22; absolute difference, +1.99% [0.78%-3.22%]; number needed to treat, 50).Among
patients with an acute ischemic stroke treated with intravenous tPA, those receiving
antiplatelet therapy before the stroke had a higher risk for sICH but better functional
outcomes than those who were not receiving antiplatelet therapy.
Type
Journal articleSubject
HumansBrain Ischemia
Cerebral Hemorrhage
Tissue Plasminogen Activator
Platelet Aggregation Inhibitors
Treatment Outcome
Registries
Risk Assessment
Risk Factors
Retrospective Studies
Aged
Aged, 80 and over
Middle Aged
Female
Male
Stroke
Administration, Intravenous
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https://hdl.handle.net/10161/21716Published Version (Please cite this version)
10.1001/jamaneurol.2015.3106Publication Info
Xian, Ying; Federspiel, Jerome J; Grau-Sepulveda, Maria; Hernandez, Adrian F; Schwamm,
Lee H; Bhatt, Deepak L; ... Peterson, Eric D (2016). Risks and Benefits Associated With Prestroke Antiplatelet Therapy Among Patients With
Acute Ischemic Stroke Treated With Intravenous Tissue Plasminogen Activator. JAMA neurology, 73(1). pp. 50-59. 10.1001/jamaneurol.2015.3106. Retrieved from https://hdl.handle.net/10161/21716.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Janet Prvu Bettger
Adjunct Associate in the Department of Orthopaedic Surgery
Dr. Bettger’s research is dedicated to establishing real world evidence aimed to improve
health care quality and policies that reduce the burden of disease and disability.
As a health services researcher and implementation scientist, her research extends
from observational studies to randomized and pragmatic trials. She is currently the
Director of Duke Roybal Center for Translational Research in the Behavioral and Social
Sciences of Aging and Director of Undergraduate Initiatives
Jerome Jeffrey Federspiel
Assistant Professor of Obstetrics and Gynecology
Dr. Federspiel is a maternal fetal medicine physician at Duke University. His clinical
and research interests focus on the care of people with cardiovascular and hematologic
complications of pregnancy.
Adrian Felipe Hernandez
Duke Health Cardiology Professor
Daniel Todd Laskowitz
Professor of Neurology
Our laboratory uses molecular biology, cell culture, and animal modeling techniques
to examine the CNS response to acute injury. In particular, our laboratory examines
the role of microglial activation and the endogenous CNS inflammatory response in
exacerbating secondary injury following acute brain insult. Much of the in vitro work
in this laboratory is dedicated to elucidating cellular responses to injury with the
ultimate goal of exploring new therapeutic interventions in the clinical settin
Eric David Peterson
Fred Cobb, M.D. Distinguished Professor of Medicine
Dr Peterson is the Fred Cobb Distinguished Professor of Medicine in the Division of
Cardiology, a DukeMed Scholar, and the Past Executive Director of the Duke Clinical
Research Institute (DCRI), Durham, NC, USA.
Dr Peterson is the Principal Investigator of the National Institute of Health, Lung
and Blood Institute (NHLBI) Spironolactone Initiation Registry Randomized Interventional
Trial in Heart Failure With Preserved Ejection Fraction (SPIRRIT) Trial He is also
the Principal I
This author no longer has a Scholars@Duke profile, so the information shown here reflects
their Duke status at the time this item was deposited.
Laine Elliott Thomas
Professor of Biostatistics & Bioinformatics
As Deputy Director, Laine Thomas, PhD provides complementary leadership in strategy
and development of the group and DCRI. She has an outstanding record of scientific
and strategic collaboration, independent research, leadership and mentoring well known
to her colleagues at the DCRI.
Thomas joined the DCRI in 2009. She serves as Associate Director for Biostatistics
at DCRI and Associate Chair for Equity, Diversity and Inclusion within the Department
of
Ying Xian
Adjunct Associate Professor in the Department of Neurology
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