Neurosurgery, Stanford University School of Medicine, Stanford, California, USA
Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
J Neurointerv Surg. 2021 Jan;13(1):8-13. doi: 10.1136/neurintsurg-2020-016008. Epub 2020 May 15.
While dual antiplatelet therapy (dAPT) is standard of care following carotid artery stenting (CAS), the optimal dAPT regimen and duration has not been established.
We canvassed a large national database (IBM MarketScan) to identify patients receiving carotid endarterectomy (CEA) or CAS for treatment of ischemic stroke or carotid artery stenosis from 2007 to 2016. We performed univariable and multivariable regression methods to evaluate the impact of covariates on post-CAS stroke-free survival, including post-discharge antiplatelet therapy.
A total of 79 084 patients diagnosed with ischemic stroke or carotid stenosis received CEA (71 178; 90.0%) or CAS (7906; 10.0%). After adjusting for covariates, <180 days prescribed post-CAS P2Y12-inhibition was associated with increased risk for stroke (<90 prescribed days HR=1.421, 95% CI 1.038 to 1.946; 90-179 prescribed days HR=1.484, 95% CI 1.045 to 2.106). The incidence of hemorrhagic complications was higher during the period of prescribed P2Y12-inhibition (1.16% per person-month vs 0.49% per person-month after discontinuation, P<0.001). The rate of extracranial hemorrhage was nearly six-fold higher while on dAPT (6.50% per patient-month vs 1.16% per patient-month, P<0.001), and there was a trend towards higher rate of intracranial hemorrhage that did not reach statistical significance (5.09% per patient-month vs 3.69% per patient-month, P=0.0556). Later hemorrhagic events beyond 30 days post-CAS were significantly more likely to be extracranial (P=0.028).
Increased duration of post-CAS dAPT is associated with lower rates of readmissions for stroke, and with increased risk of hemorrhagic complications, particularly extracranial hemorrhage. The potential benefit of prolonging dAPT with regard to ischemic complications must be balanced with the corresponding increased risk of predominantly extracranial hemorrhagic complications.
虽然在颈动脉支架置入术（CAS）后进行双联抗血小板治疗（dAPT）是标准的治疗方法，但最佳的 dAPT 方案和持续时间尚未确定。
我们调查了一个大型的全国性数据库（IBM MarketScan），以确定 2007 年至 2016 年期间因缺血性卒中和颈动脉狭窄而接受颈动脉内膜切除术（CEA）或 CAS 治疗的患者。我们使用单变量和多变量回归方法评估了围手术期抗血小板治疗对 CAS 后无卒中生存的影响。
共纳入 79084 例诊断为缺血性卒中和颈动脉狭窄的患者，其中 71178 例（90.0%）接受了 CEA，7906 例（10.0%）接受了 CAS。调整混杂因素后，CAS 后接受的 P2Y12 抑制剂治疗时间<180 天与卒中风险增加相关（<90 天处方 HR=1.421，95%CI 1.038 至 1.946；90-179 天处方 HR=1.484，95%CI 1.045 至 2.106）。在接受 P2Y12 抑制剂治疗期间，出血并发症的发生率更高（每患者月 1.16% vs. 停药后每患者月 0.49%，P<0.001）。在接受 dAPT 治疗时，颅外出血的发生率几乎高出六倍（每患者月 6.50% vs. 每患者月 1.16%，P<0.001），颅内出血的发生率虽呈上升趋势，但无统计学意义（每患者月 5.09% vs. 每患者月 3.69%，P=0.0556）。CAS 后 30 天以上的迟发性出血事件更有可能是颅外出血（P=0.028）。
延长 CAS 后 dAPT 的持续时间与较低的卒中再入院率相关，并且出血并发症的风险增加，尤其是颅外出血。延长 dAPT 对缺血性并发症的潜在益处必须与主要为颅外出血并发症的相应增加风险相平衡。
