Department of Neurology, University of Florida, Gainesville.
Department of Neurology, Yale School of Medicine, New Haven, Connecticut.
JAMA Neurol. 2024 Jul 1;81(7):722-731. doi: 10.1001/jamaneurol.2024.1312.
Intravenous alteplase (IV-tPA) can be administered to patients with acute ischemic stroke but is associated with symptomatic intracerebral hemorrhage (sICH). It is unclear if patients taking prestroke dual antiplatelet therapy (DAPT) are at higher risk of sICH.
To determine the associated risk of sICH in patients taking prestroke dual antiplatelet therapy receiving alteplase for acute ischemic stroke using propensity score matching analysis.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the American Heart Association and American Stroke Association Get With The Guidelines-Stroke (GWTG-Stroke) registry between 2013 and 2021. Data were obtained from hospitals in the GWTG-Stroke registry. This study included patients hospitalized with acute ischemic stroke and treated with IV-tPA. Data were analyzed from January 2013 to December 2021.
Prestroke DAPT before treatment with IV-tPA for acute ischemic stroke.
sICH, In-hospital death, discharge modified Rankin scale score, and other life-threatening systemic hemorrhages.
Of 409 673 participants, 321 819 patients (mean [SD] age, 68.6 [15.1] years; 164 587 female [51.1%]) who were hospitalized with acute ischemic stroke and treated with IV-tPA were included in the analysis. The rate of sICH was 2.9% (5200 of 182 344), 3.8% (4457 of 117 670), and 4.1% (893 of 21 805) among patients treated with no antiplatelet therapy, single antiplatelet therapy (SAPT), and DAPT, respectively (P < .001). In adjusted analyses after propensity score subclassification, both SAPT (odds ratio [OR], 1.13; 95% CI, 1.07-1.19) and DAPT (OR, 1.28; 95% CI, 1.14-1.42) were associated with increased risks of sICH. Prestroke antiplatelet medications were associated with lower odds of discharge mRS score of 2 or less compared with no medication (SAPT OR, 0.92; 95% CI, 0.90-0.95; DAPT OR, 0.94; 95% CI, 0.88-0.98). Results of a subgroup analysis of patients taking DAPT exposed to aspirin-clopidogrel vs aspirin-ticagrelor combination therapy were not significant (OR, 1.35; 95% CI, 0.84-1.86).
Prestroke DAPT was associated with a significantly elevated risk of sICH among patients with ischemic stroke who were treated with thrombolysis; however, the absolute increase in risk was small. Patients exposed to antiplatelet medications did not have excess sICH compared with landmark trials, which demonstrated overall clinical benefit of thrombolysis therapy for acute ischemic stroke.
急性缺血性脑卒中患者可使用静脉注射重组组织型纤溶酶原激活物（IV-tPA）治疗，但会引起症状性颅内出血（sICH）。目前尚不清楚正在服用缺血性脑卒中前双联抗血小板治疗（DAPT）的患者是否有更高的 sICH 风险。
通过倾向评分匹配分析，确定正在服用缺血性脑卒中前双联抗血小板治疗且接受 IV-tPA 治疗急性缺血性脑卒中的患者 sICH 的风险。
设计、地点和参与者：本队列研究使用了美国心脏协会和美国中风协会 Get With The Guidelines-Stroke（GWTG-Stroke）登记处 2013 年至 2021 年的数据。数据来自 GWTG-Stroke 登记处的医院。本研究纳入了因急性缺血性脑卒中住院且接受 IV-tPA 治疗的患者。数据分析于 2013 年 1 月至 2021 年 12 月进行。
IV-tPA 治疗急性缺血性脑卒中前的缺血性脑卒中前 DAPT。
sICH、住院期间死亡、出院改良 Rankin 量表评分和其他危及生命的全身性出血。
在 409673 名参与者中，有 321819 名患者（平均[标准差]年龄，68.6[15.1]岁；女性 164587 名[51.1%]）因急性缺血性脑卒中住院并接受 IV-tPA 治疗，被纳入分析。无抗血小板治疗、单药抗血小板治疗（SAPT）和 DAPT 治疗患者的 sICH 发生率分别为 2.9%（5200/182344）、3.8%（4457/117670）和 4.1%（893/21805）（P<0.001）。在倾向评分亚分类后进行调整分析，SAPT（比值比[OR]，1.13；95%置信区间[CI]，1.07-1.19）和 DAPT（OR，1.28；95% CI，1.14-1.42）均与 sICH 风险增加相关。与未服用药物相比，缺血性脑卒中前抗血小板药物与较低的出院 mRS 评分 2 分或更低相关（SAPT OR，0.92；95% CI，0.90-0.95；DAPT OR，0.94；95% CI，0.88-0.98）。对接受 DAPT 治疗且暴露于阿司匹林-氯吡格雷与阿司匹林-替格瑞洛联合治疗的患者进行亚组分析的结果不显著（OR，1.35；95% CI，0.84-1.86）。
缺血性脑卒中前 DAPT 与接受溶栓治疗的缺血性脑卒中患者 sICH 的风险显著升高相关；然而，风险的绝对增加幅度较小。与里程碑试验相比，接受抗血小板药物治疗的患者并未出现 sICH 过多，而里程碑试验表明溶栓治疗对急性缺血性脑卒中具有整体临床获益。
