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Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Aspirin-ticagrelor use after mild acute ischemic stroke: Findings from the get with the guidelines-stroke registry
Ava L Liberman1, Cenai Zhang1, Sara K Rostanski2
1Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
Insights
Aspirin-ticagrelor is rarely used for mild ischemic stroke prevention, despite guidelines. Both aspirin-ticagrelor and aspirin-clopidogrel use increased over time in this patient population.
Area of Science:
- Neurology
- Cardiology
- Clinical Pharmacy
Background:
- Current guidelines suggest aspirin-ticagrelor for stroke prevention in mild acute ischemic stroke.
- Real-world utilization of this dual antiplatelet therapy (DAPT) regimen remains unclear.
Purpose of the Study:
- To determine the frequency of aspirin-ticagrelor use in patients with mild acute ischemic stroke.
- To analyze trends in DAPT prescribing and factors associated with aspirin-ticagrelor use.
Main Methods:
- Cross-sectional analysis of the Get With The Guidelines-Stroke registry (2017-2023).
- Included patients with mild ischemic stroke (NIHSS <6) without DAPT contraindications.
- Used logistic regression to identify factors associated with aspirin-ticagrelor prescription.
Main Results:
- Only 1.3% of over 1 million patients received aspirin-ticagrelor at discharge.
- Aspirin-clopidogrel was prescribed to 44.0% of patients.
- Use of both DAPT regimens increased over the study period.
- Factors associated with aspirin-ticagrelor included coronary artery disease and Asian race; rural settings and primary stroke centers were inversely associated.
Conclusions:
- Aspirin-ticagrelor is infrequently used for mild acute ischemic stroke, contrasting with guidelines.
- Both aspirin-ticagrelor and aspirin-clopidogrel prescribing increased over time.
- Further research may be needed to understand barriers to aspirin-ticagrelor adoption.
Background:
Recent guidelines suggest that aspirin-ticagrelor may be considered for stroke prevention after mild acute ischemic stroke. However, it is unclear how commonly this dual antiplatelet therapy (DAPT) regimen is used in practice.
Methods:
We performed a cross-sectional analysis of the Get With The Guidelines-Stroke registry 2017-2023. Patients with a non-cardioembolic mild ischemic stroke (defined as NIHSS <6) who presented within 24 hours of last known well without a contraindication to DAPT were included. The primary study outcome was the proportion of patients prescribed aspirin-ticagrelor at hospital discharge; temporal patterns of prescribing aspirin-ticagrelor and aspirin-clopidogrel over time are also described. In addition to standard tests of comparison, we used multiple logistic regression to evaluate associations between patient and facility factors and aspirin-ticagrelor use reported as odds ratios (OR) with 95% confidence intervals (CI).
Results:
Among 1,018,736 patients meeting study criteria, 478,049 (46.9%) were female and median age was 68 (IQR: 59, 78) years. A total of 12,845 (1.3%) patients were discharged on aspirin-ticagrelor whereas 448,348 (44.0%) were discharged on aspirin-clopidogrel. Prescriptions for aspirin-ticagrelor and for aspirin-clopidogrel significantly increased over the study time-period. In regression analysis, coronary artery disease/prior myocardial infarction (OR: 2.6 [95% CI: 2.5-2.7]), Asian race (OR: 2.1 [95% CI: 1.9-2.2]), aspirin-clopidogrel prescription upon admission (OR: 2.0 [95% CI:1.9-2.1]), and history of stroke/TIA (OR: 1.98 [95% CI: (1.9-2.1)]), were substantially associated with aspirin-ticagrelor use whereas lacking insurance/self-pay (OR: 0.7 [95% CI: 0.6-0.8]), rural setting (OR: 0.8 [95% 0.7-0.9]), and primary stroke centers (OR: 0.3 [95% CI: 0.3-0.4]) were inversely associated with aspirin-ticagrelor. In the subgroup of 176,897 (17.4%) patients with NIHSS 4-5, 74,912 (50.8%) were discharged on aspirin-clopidogrel and 2,394 (1.4%) on aspirin-ticagrelor.
Conclusion:
Unlike aspirin-clopidogrel, aspirin-ticagrelor is infrequently administered after mild acute ischemic stroke (NIHSS <6) despite current guidelines, though the use of both DAPT regimens increased over time.
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