Contemporary Prestroke Dual Antiplatelet Use and Symptomatic Intracerebral Hemorrhage Risk After Thrombolysis

Area of Science:

• Neurology
• Cardiology
• Pharmacology

Background:

• Intravenous alteplase (IV-tPA) is a critical treatment for acute ischemic stroke.
• Symptomatic intracerebral hemorrhage (sICH) is a known complication of IV-tPA.
• The impact of prestroke dual antiplatelet therapy (DAPT) on sICH risk is not well-defined.

Purpose of the Study:

• To investigate the association between prestroke DAPT and the risk of sICH in patients receiving IV-tPA for acute ischemic stroke.
• To evaluate the safety and efficacy of IV-tPA in patients on DAPT.

Main Methods:

• A large cohort study utilizing the Get With The Guidelines-Stroke registry (2013-2021).
• Propensity score matching analysis was employed to compare outcomes between patients with and without prestroke DAPT.
• Included patients with acute ischemic stroke treated with IV-tPA, analyzing rates of sICH, in-hospital death, and discharge modified Rankin Scale score.

Main Results:

• Patients on prestroke DAPT had a significantly higher risk of sICH (OR, 1.28; 95% CI, 1.14-1.42) compared to those not on antiplatelet therapy.
• The absolute increase in sICH risk associated with DAPT was small.
• Patients on DAPT or single antiplatelet therapy (SAPT) had better functional outcomes at discharge (mRS ≤ 2) compared to those on no antiplatelet therapy.

Conclusions:

• Prestroke DAPT is associated with a statistically significant but small increase in sICH risk following IV-tPA for acute ischemic stroke.
• Despite the elevated risk, patients on DAPT did not experience excess sICH compared to landmark trial data, suggesting overall clinical benefit from thrombolysis.
• Further research may explore optimal antiplatelet strategies in stroke patients undergoing thrombolysis.