Lee Hak-Loh, Kim Joon-Tae, Lee Ji Sung, Park Man-Seok, Choi Kang-Ho, Cho Ki-Hyun, Kim Beom Joon, Park Jong-Moo, Kang Kyusik, Lee Soo Joo, Kim Jae Guk, Cha Jae-Kwan, Kim Dae-Hyun, Park Tai Hwan, Park Sang-Soon, Lee Kyung Bok, Lee Jun, Hong Keun-Sik, Cho Yong-Jin, Park Hong-Kyun, Lee Byung-Chul, Yu Kyung-Ho, Sun Oh Mi, Kim Dong-Eog, Ryu Wi-Sun, Choi Jay Chol, Kwon Jee-Hyun, Kim Wook-Joo, Shin Dong-Ick, Sohn Sung Il, Hong Jeong-Ho, Lee Juneyoung, Bae Hee-Joon
Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea (H.-L.L., J.-T.K., M.-S.P., K.-H. Choi, K.-H. Cho).
Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (J.S.L.).
Circ Cardiovasc Qual Outcomes. 2020 Nov;13(11):e006474. doi: 10.1161/CIRCOUTCOMES.119.006474. Epub 2020 Nov 17.
This study compared the effectiveness of dual antiplatelet therapy (DAPT) with clopidogrel-aspirin with that of aspirin monotherapy (AM) in mild-to-moderate acute ischemic stroke considering the risk of recurrent stroke using the Stroke Prognosis Instrument II (SPI-II) score.
This study is a retrospective analysis of data from a prospective, nationwide, multicenter stroke registry database between January 2011 and July 2018. We included patients with mild-to-moderate (National Institutes of Health Stroke Scale score ≤10), acute (within 24 hours of onset), noncardioembolic ischemic stroke. The primary outcome was a 3-month composite of stroke (either hemorrhagic or ischemic), myocardial infarction, and all-cause mortality. Propensity scores using the inverse probability of treatment weighting method were used to mitigate baseline imbalances between the DAPT and AM groups and within each subgroup considering SPI-II scores.
Among the 15 430 patients (age, 66±13 years; men, 62.0%), 45.1% (n=6960) received DAPT and 54.9% (n=8470) received AM. Primary outcome events were significantly more frequent in the AM group (16.7%) than in the DAPT group (15.5%; =0.03). Weighted Cox proportional hazards models showed a reduced risk of 3-month primary vascular events in the DAPT group versus the AM group (hazard ratio, 0.84 [0.78-0.92]; <0.001), with no interaction between acute treatment type and SPI-II risk subgroups (=0.44). However, among the high-risk patients with SPI-II scores >7, a substantially larger absolute benefit was observed for 3-month composite vascular events in the DAPT group (weighted absolute risk differences, 5.4%), whereas smaller absolute benefits were observed among patients in the low- or medium-risk SPI-II subgroups (1.7% and 2.4%, respectively).
Treatment with clopidogrel-aspirin was associated with a reduction in 3-month vascular events compared with AM in mild-to-moderate acute noncardioembolic ischemic stroke patients. Larger magnitudes of the effects of DAPT with clopidogrel-aspirin were observed in the high-risk subgroup by SPI-II risk scores.
本研究使用卒中预后工具II（SPI-II）评分，比较了氯吡格雷联合阿司匹林双重抗血小板治疗（DAPT）与阿司匹林单药治疗（AM）在轻度至中度急性缺血性卒中患者中预防复发性卒中的有效性。
本研究是一项对2011年1月至2018年7月期间前瞻性、全国性、多中心卒中登记数据库数据的回顾性分析。纳入轻度至中度（美国国立卫生研究院卒中量表评分≤10分）、急性（发病24小时内）、非心源性栓塞性缺血性卒中患者。主要结局为3个月时卒中（出血性或缺血性）、心肌梗死和全因死亡率的复合结局。采用治疗权重逆概率法的倾向评分来减轻DAPT组和AM组之间以及各亚组内基于SPI-II评分的基线不平衡。
在15430例患者（年龄66±13岁；男性占62.0%）中，45.1%（n = 6960）接受DAPT，54.9%（n = 8470）接受AM。AM组的主要结局事件发生率（16.7%）显著高于DAPT组（15.5%；P = 0.03）。加权Cox比例风险模型显示，与AM组相比，DAPT组3个月时主要血管事件风险降低（风险比，0.84[0.78 - 0.92]；P < 0.001），急性治疗类型与SPI-II风险亚组之间无交互作用（P = 0.44）。然而，在SPI-II评分>7的高危患者中，DAPT组3个月时复合血管事件的绝对获益明显更大（加权绝对风险差异为5.4%），而在SPI-II低风险或中风险亚组患者中观察到的绝对获益较小（分别为1.7%和2.4%）。
在轻度至中度急性非心源性栓塞性缺血性卒中患者中，与AM相比，氯吡格雷联合阿司匹林治疗可降低3个月时的血管事件发生率。根据SPI-II风险评分，在高危亚组中观察到氯吡格雷联合阿司匹林DAPT的效果更显著。
