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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Ischaemic stroke despite antiplatelet therapy: Causes and outcomes
Norbert Silimon1, Boudewijn Drop1, Leander Clénin1
1Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland.
Insights
Ischaemic stroke can occur despite antiplatelet therapy (APT). Patients experiencing stroke while on APT face a higher risk of recurrent stroke, though outcomes are not significantly worse.
Area of Science:
- Neurology
- Cardiology
- Public Health
Background:
- Ischaemic stroke remains a significant health concern, even in patients undergoing antiplatelet therapy (APT).
- Understanding the characteristics and outcomes of these 'breakthrough' strokes is crucial for optimizing patient care and prevention strategies.
Purpose of the Study:
- To investigate the frequency, causes, and outcomes of ischaemic stroke occurring in patients despite the use of antiplatelet therapy (APT).
- To determine the association between prior APT use and unfavourable functional outcomes or recurrent ischaemic stroke.
Main Methods:
- A cohort study utilizing data from the Swiss Stroke Registry (01/2014-07/2022) including patients with imaging-confirmed ischaemic stroke.
- Assessment of prior antiplatelet therapy (APT) status, stroke aetiology using the modified TOAST classification, and 3-month outcomes (functional status, recurrent stroke).
- Regression models were employed to analyze the association of prior APT with adverse outcomes.
Main Results:
- Out of 53,352 patients, 33.3% were on APT. Among patients with a history of ischaemic stroke/TIA, 55.2% were on APT.
- The aetiology of ischaemic stroke despite APT was diverse, with cardiac embolism (23.6%) and large artery atherosclerosis (19.8%) being most common.
- Prior APT was not associated with unfavourable functional outcome or death at 3 months, but was linked to a significantly increased risk of recurrent stroke (aOR 1.26, p < 0.001).
Conclusions:
- Approximately one-third of ischaemic strokes occurred in patients on APT, highlighting the limitations of this therapy in certain cases.
- Strokes occurring despite APT have a heterogeneous aetiology and are associated with an elevated risk of subsequent recurrent stroke.
- These findings underscore the need for continued research into stroke prevention and management in patients receiving antiplatelet therapy.
Background:
Ischaemic stroke may occur despite antiplatelet therapy (APT). We aimed to investigate frequency, potential causes and outcomes in patients with ischaemic stroke despite APT.
Methods:
In this cohort study, we enrolled patients with imaging-confirmed ischaemic stroke from the Swiss Stroke Registry (01/2014-07/2022). We determined the frequency of prior APT, assessed stroke aetiology (modified TOAST classification) and determined the association of prior APT with unfavourable functional outcome (modified Rankin Scale score 3-6) and recurrent ischaemic stroke at 3 months using regression models.
Results:
Among 53,352 patients, 27,484 (51.5%) had no prior antithrombotic treatment, 17,760 (33.3%) were on APT, 7039 (13.2%) on anticoagulation and 1069 (2.0%) were on APT + anticoagulation. In patients with a history of ischaemic stroke/TIA (n = 11,948; 22.4%), 2401 (20.1%) had no prior antithrombotic therapy, 6594 (55.2%) were on APT, 2489 (20.8%) on anticoagulation and 464 (3.9%) on APT + anticoagulation. Amongst patients with ischaemic stroke despite APT, aetiology was large artery atherosclerosis in 19.8% (n = 3416), cardiac embolism in 23.6% (n = 4059), small vessel disease in 11.7% (n = 2011), other causes in 7.4% (n = 1267), more than one cause in 6.3% (n = 1078) and unknown cause in 31.3% (n = 5388). Prior APT was not independently associated with unfavourable outcome (aOR = 1.06; 95% CI: 0.98-1.14; p = 0.135) or death (aOR = 1.10; 95% CI: 0.99-1.21; p = 0.059) at 3-months but with increased odds of recurrent stroke (6.0% vs 4.3%; aOR 1.26; 95% CI: 1.11-1.44; p < 0.001).
Conclusions:
One-third of ischaemic strokes occurred despite APT and 20% of patients with a history of ischaemic stroke had no antithrombotic therapy when having stroke recurrence. Aetiology of breakthrough strokes despite APT is heterogeneous and these patients are at increased risk of recurrent stroke.
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