双重抗血小板治疗在轻度缺血性卒中或短暂性脑缺血发作合并癌症患者中的有效性和安全性：READAPT研究的二次分析
Effectiveness and safety of dual antiplatelet therapy in patients with minor ischemic stroke or transient ischemic attack and cancer: A secondary analysis of the READAPT study.
作者信息
Foschi Matteo, De Santis Federico, D'Anna Lucio, Romoli Michele, Tassinari Tiziana, Saia Valentina, Cenciarelli Silvia, Bedetti Chiara, Padiglioni Chiara, Censori Bruno, Puglisi Valentina, Vinciguerra Luisa, Guarino Maria, Barone Valentina, Zedde Marialuisa, Grisendi Ilaria, Diomedi Marina, Bagnato Maria Rosaria, Petruzzellis Marco, Mezzapesa Domenico Maria, Inchingolo Vincenzo, Cappellari Manuel, Zivelonghi Cecilia, Candelaresi Paolo, Andreone Vincenzo, Rinaldi Giuseppe, Bavaro Alessandra, Cavallini Anna Maria, Piscaglia Maria Grazia, Terruso Valeria, Mannino Marina, Pezzini Alessandro, Frisullo Giovanni, Muscia Francesco, Paciaroni Maurizio, Mosconi Maria Giulia, Zini Andrea, Leone Ruggiero, Palmieri Carmela, Cupini Letizia Maria, Marcon Michela, Tassi Rossana, Sanzaro Enzo, Papiri Giulio, Viticchi Giovanna, Orsucci Daniele, Falcou Anne, Diamanti Susanna, Tarletti Roberto, Nencini Patrizia, Rota Eugenia, Sepe Federica Nicoletta, Ferrandi Delfina, Caputi Luigi, Volpi Gino, Laspada Salvatore, Beccia Mario, Rinaldi Claudia, Mastrangelo Vincenzo, Di Blasio Francesco, Invernizzi Paolo, Pelliccioni Giuseppe, De Angelis Maria Vittoria, Bonanni Laura, Ruzza Giampietro, Caggia Emanuele Alessandro, Russo Monia, Tonon Agnese, Acciarri Maria Cristina, Anticoli Sabrina, Roberti Cinzia, Manobianca Giovanni, Scaglione Gaspare, Pistoia Francesca, Fortini Alberto, De Boni Antonella, Sanna Alessandra, Chiti Alberto, Caggiula Marcella, Masato Maela, Del Sette Massimo, Passarelli Francesco, Bongioanni Maria Roberta, De Michele Manuela, Ricci Stefano, De Matteis Eleonora, Ornello Raffaele, Sacco Simona
机构信息
Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy.
Department of Brain Sciences, Imperial College London, London, UK; Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK.
出版信息
Eur Stroke J. 2025 Apr 23:23969873251333282. doi: 10.1177/23969873251333282.
INTRODUCTION
Patients with ischemic stroke or transient ischemic attack (TIA) and cancer face unique risks of recurrent ischemic events and bleeding. It is unclear whether this increased risk is present even in patients with minor ischemic stroke or transient ischemic attack (TIA) receiving dual antiplatelet therapy (DAPT). This study aimed to evaluate the impact of cancer on the short-term outcomes after DAPT in patients with non-cardioembolic minor ischemic stroke or high-risk TIA.
PATIENTS AND METHODS
This was a secondary analysis of the prospective multicentric READAPT study (NCT05476081), including patients with non-cardioembolic minor ischemic stroke (NIHSS ⩽ 5) or high-risk TIA (ABCD2 ⩾4) who initiated DAPT within 48 h of symptom onset. The primary effectiveness outcome was the 90-day risk of new ischemic stroke or other vascular events (TIA, myocardial infarction, death due to vascular causes). Secondary outcomes included 90-day mRS score distribution and all-cause mortality. The primary safety outcome was the 90-day risk of any bleeding, with secondary safety outcomes including 24-h hemorrhagic transformation. We used Inverse Probability Weighting to compare outcomes between patients with and without cancer.
RESULTS
From 2278 patients in the READAPT study cohort, we included 1561 patients (mean age 70.3 ± 11.7 years; 65.4% males), of whom 206 (13.2%) had cancer, categorized as either active (27.7%) or in remission (72.3%). After weighting, overall cancer patients had a higher risk of 90-day new ischemic stroke or other vascular events (weighted HR 1.78, 95% CI 1.20-2.63, = 0.004) and worse 90-day mRS score distribution (OR 1.24, 95% CI 1.10-1.41, < 0.001) compared to patients without cancer. The 90-day risk of bleeding did not differ between cancer and no-cancer groups overall. When analyzing cancer subgroups, patients with active cancer had significantly higher risk of 90-day ischemic stroke or other vascular (weighted HR 2.75, 95% CI 1.70-4.45, < 0.001) and any bleeding (weighted HR 2.51, 95% CI 1.27-4.97, = 0.008) events compared to no-cancer patients. In contrast, patients with cancer in remission had comparable risks to those without cancer. Furthermore, hematological malignancies were associated with a substantially higher risk of 90-day new ischemic stroke or other vascular events compared to solid tumors (weighted HR 8.15, 95% CI 5.06-13.14, < 0.001).
CONCLUSIONS
Patients with minor ischemic stroke or high-risk TIA and active cancer have increased risk of ischemic and bleeding events after DAPT. Conversely, patients with cancer in remission have similar outcomes compared to those with no cancer.
引言
缺血性中风或短暂性脑缺血发作（TIA）患者以及癌症患者面临复发性缺血事件和出血的独特风险。目前尚不清楚即使在接受双联抗血小板治疗（DAPT）的轻度缺血性中风或短暂性脑缺血发作（TIA）患者中是否也存在这种增加的风险。本研究旨在评估癌症对非心源性轻度缺血性中风或高危TIA患者接受DAPT后短期结局的影响。
患者与方法
这是对前瞻性多中心READAPT研究（NCT05476081）的二次分析，纳入症状发作后48小时内开始接受DAPT的非心源性轻度缺血性中风（美国国立卫生研究院卒中量表[NIHSS]≤5）或高危TIA（ABCD2≥4）患者。主要有效性结局是90天内发生新的缺血性中风或其他血管事件（TIA、心肌梗死、血管性死亡）的风险。次要结局包括90天改良Rankin量表（mRS）评分分布和全因死亡率。主要安全性结局是90天内发生任何出血的风险，次要安全性结局包括24小时内出血性转化。我们使用逆概率加权法比较有癌症和无癌症患者的结局。
结果
在READAPT研究队列的2278例患者中，我们纳入了1561例患者（平均年龄70.3±11.7岁；65.4%为男性），其中206例（13.2%）患有癌症，分为活动期（27.7%）或缓解期（72.3%）。加权后，总体癌症患者90天内发生新的缺血性中风或其他血管事件的风险更高（加权风险比[HR]1.78，95%置信区间[CI]1.20 - 2.63，P = 0.004），90天mRS评分分布更差（比值比[OR]1.24，95%CI 1.10 - 1.41，P < 0.001），与无癌症患者相比。总体而言，癌症组和非癌症组90天内出血风险无差异。在分析癌症亚组时，与无癌症患者相比，活动期癌症患者90天内发生缺血性中风或其他血管事件（加权HR 2.75，95%CI 1.70 - 4.45，P < 0.001）和任何出血事件（加权HR 2.51，95%CI 1.27 - 4.97，P = 0.008）的风险显著更高。相比之下，缓解期癌症患者的风险与无癌症患者相当。此外，与实体瘤相比，血液系统恶性肿瘤患者90天内发生新的缺血性中风或其他血管事件的风险显著更高（加权HR 8.15，95%CI 5.06 - 13.14，P < 0.001）。
结论
轻度缺血性中风或高危TIA且患有活动期癌症的患者在接受DAPT后发生缺血和出血事件的风险增加。相反，缓解期癌症患者与无癌症患者的结局相似。
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