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Updated: Jun 4, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Dual Antiplatelet Treatment up to 72 Hours After Ischemic Stroke Stratified by Risk Profile: A Post Hoc Analysis
Yanli Zhang1,2, Xuan Wang1,2, Ying Gao1,2
1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (Y.Z., X.W., Y.G., W.C., H.Y., T.W., Y.Y., Q.Z., M.W., J.J., C.W., Yongjun Wang, Yilong Wang, Y.P.).
Insights
Clopidogrel-aspirin therapy benefits patients with mild stroke or high-risk TIA who have a low risk profile. This combination therapy did not show increased bleeding risk across risk groups.
Area of Science:
- Neurology
- Cardiology
- Clinical Trials
Background:
- Recurrence risk influences antiplatelet therapy effectiveness.
- Acute mild stroke and high-risk transient ischemic attack (TIA) require risk-stratified treatment.
- Evaluating clopidogrel-aspirin versus aspirin based on patient risk profiles.
Purpose of the Study:
- To assess the efficacy and safety of clopidogrel-aspirin compared to aspirin alone.
- To determine if antiplatelet therapy benefits vary by stroke recurrence risk profile.
- To analyze outcomes in acute mild stroke or high-risk TIA patients treated within 72 hours of symptom onset.
Main Methods:
- Secondary post hoc analysis of the INSPIRES randomized clinical trial.
- Inclusion of patients aged 35-80 with acute mild ischemic stroke or high-risk TIA.
- Stratification by Essen Stroke Risk Score (ESRS) and modified ESRS for risk assessment.
- Primary outcomes: new stroke and moderate-to-severe bleeding within 90 days.
Main Results:
- Clopidogrel-aspirin reduced new stroke risk in low-risk patients (ESRS <3) compared to aspirin (HR 0.67).
- No significant stroke risk reduction was observed in high-risk patients (ESRS ≥3) with clopidogrel-aspirin (HR 0.92).
- Bleeding risk did not significantly differ across risk profile subgroups for either therapy.
Conclusions:
- Low-risk patients with acute mild stroke or high-risk TIA benefit more from clopidogrel-aspirin initiated within 72 hours.
- Risk stratification is crucial for optimizing antiplatelet therapy selection in these patient populations.
- The INSPIRES trial data supports tailored antiplatelet strategies based on individual risk profiles.
Background:
Risk profile of recurrence may influence the effect of antiplatelet therapy. This study aimed to evaluate the efficacy and safety of clopidogrel-aspirin initiated within 72 hours after symptom onset for acute mild stroke or high-risk transient ischemic attack stratified by risk profile.
Methods:
This is a secondary post hoc analysis of the INSPIRES (Intensive Statin and Antiplatelet Therapy for Acute High-risk Intracranial or Extracranial Atherosclerosis) randomized clinical trial that enrolled patients 35 to 80 years old with acute mild ischemic stroke or high-risk transient ischemic attack between 2018 and 2022. Patients were stratified into different groups based on the Essen Stroke Risk Score (ESRS) and modified ESRS. The primary efficacy outcome was any new stroke within 90 days. The primary safety outcome was moderate-to-severe bleeding within 90 days.
Results:
Among 6100 patients (3050 each in the clopidogrel-aspirin group and aspirin group), the median age was 65 years (interquartile range, 57-71 years), and 3915 (64.2%) were male. Clopidogrel-aspirin was associated with a reduced risk of new stroke in patients with an ESRS of <3 (hazard ratio [HR], 0.67 [95% CI, 0.52-0.86]), but not in those with an ESRS of ≥3 (HR, 0.92 [95% CI, 0.72-1.18]), compared with aspirin (Pinteraction=0.07). Similar results were found in patients stratified by modified ESRS (modified ESRS <6 in male and <5 in female: HR, 0.68 [95% CI, 0.55-0.83]; modified ESRS ≥6 in male and ≥5 in female: HR, 1.14 [95% CI, 0.82-1.59]; Pinteraction=0.01). The association between antiplatelet therapy and the moderate-to-severe bleeding did not differ across risk profile subgroups (ESRS of <3: HR, 1.35 [95% CI, 0.54-3.35]; ESRS of ≥3: HR, 3.21 [95% CI, 1.18-8.78]; Pinteraction=0.21; modified ESRS of <6 in male and <5 in female: HR, 1.96 [95% CI, 0.88-4.36]; modified ESRS of ≥6 in male and ≥5 in female: HR, 2.27 [95% CI, 0.70-7.39]; Pinteraction=0.85).
Conclusions:
This post hoc analysis of the INSPIRES trial showed that patients with a low level of risk profile assessed by ESRS received greater benefit from clopidogrel-aspirin initiated within 72 hours after symptom onset than aspirin alone.
Registration:
URL: https://www.clinicaltrials.gov; Unique identifier: NCT03635749.
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