Department of Neurology, Chonnam National University Hospital Chonnam National University Medical School Gwangju Korea.
Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center University of Ulsan College of Medicine Seoul Korea.
J Am Heart Assoc. 2024 May 21;13(10):e033611. doi: 10.1161/JAHA.123.033611. Epub 2024 May 18.
Recent clinical trials established the benefit of dual antiplatelet therapy with aspirin and clopidogrel (DAPT-AC) in early-presenting patients with minor ischemic stroke. However, the impact of these trials over time on the use and outcomes of DAPT-AC among the patients with nonminor or late-presenting stroke who do not meet the eligibility criteria of these trials has not been delineated.
In a multicenter stroke registry, this study examined yearly changes from April 2008 to August 2022 in DAPT-AC use for stroke patients ineligible for CHANCE/POINT (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events/Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) clinical trials due to National Institutes of Health Stroke Scale >4 or late arrival beyond 24 hours of onset. A total of 32 118 patients (age, 68.1±13.1 years; male, 58.5%) with National Institutes of Health Stroke Scale of 4 (interquartile range, 1-7) were analyzed. In 2008, DAPT-AC was used in 33.0%, other antiplatelets in 62.7%, and no antiplatelet in 4.3%. The frequency of DAPT-AC was relatively unchanged through 2013, when the CHANCE trial was published, and then increased steadily, reaching 78% in 2022, while other antiplatelets decreased to 17.8% in 2022 (<0.001). From 2011 to 2022, clinical outcomes nonsignificantly improved, with an average relative risk reduction of 2%/y for the composite of stroke, myocardial infarction, and all-cause mortality, both among patients treated with DAPT-AC and patients treated with other antiplatelets.
Use of DAPT-AC in stroke patients with stroke ineligible for recent DAPT clinical trials increased markedly and steadily after CHANCE publication in 2013, reaching deployment in nearly 4 of every 5 patients by 2022. The secondary prevention in patients with ischemic stroke seems to be gradually improving, possibly due to the enhancement of risk factor control.
最近的临床试验证实，在早期出现的轻度缺血性卒中患者中，使用阿司匹林和氯吡格雷的双联抗血小板治疗（DAPT-AC）有益。然而，这些试验随着时间的推移对不符合这些试验入选标准的非小或迟发性卒中患者的 DAPT-AC 使用及其结局的影响尚未明确。
在一项多中心卒中登记研究中，本研究考察了 2008 年 4 月至 2022 年 8 月期间，由于国立卫生研究院卒中量表（NIHSS）>4 分或发病后 24 小时以上延迟就诊，不符合 CHANCE/POINT（高风险急性非致残性脑血管事件患者中的氯吡格雷/新 TIA 和小卒中的血小板导向抑制）临床试验入选标准的卒中患者中，DAPT-AC 的使用变化情况。共分析了 32118 例 NIHSS 为 4 分（四分位数间距 1-7）的患者（年龄 68.1±13.1 岁；男性 58.5%）。2008 年，DAPT-AC 的使用率为 33.0%，其他抗血小板药物为 62.7%，无抗血小板药物为 4.3%。2013 年 CHANCE 试验发表后，DAPT-AC 的使用率相对保持不变，随后稳步上升，2022 年达到 78%，而其他抗血小板药物则降至 2022 年的 17.8%（<0.001）。2011 年至 2022 年，临床结局无显著改善，DAPT-AC 治疗和其他抗血小板药物治疗的患者的复合终点（卒中、心肌梗死和全因死亡率）的平均相对风险降低率为 2%/年。
在 2013 年 CHANCE 试验发表后，不符合最近 DAPT 临床试验入选标准的卒中患者中 DAPT-AC 的使用明显且稳步增加，到 2022 年，近 4 例患者中就有 3 例使用了 DAPT-AC。缺血性卒中患者的二级预防似乎在逐渐改善，可能是由于危险因素控制的增强。
