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Published on: May 6, 2014
Low-dose rivaroxaban plus antiplatelet therapy for symptomatic intracranial atherosclerotic stenosis: A prospective
Ding Zhang1, Zhaoyang Zhao1, Yiwei Qian1
1Department of Neurology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
Insights
Dual pathway inhibition (DPI) with low-dose rivaroxaban plus antiplatelet therapy (APT) significantly reduced recurrent stroke risk in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). This dual pathway inhibition strategy showed a lower incidence of major adverse cardiovascular events compared to APT alone.
Area of Science:
- Cardiovascular Medicine
- Neurology
- Pharmacology
Background:
- Symptomatic intracranial atherosclerotic stenosis (sICAS) presents significant challenges for antithrombotic treatment strategies.
- Dual pathway inhibition (DPI) has shown promise in managing coronary and peripheral artery disease, suggesting potential benefits for cerebrovascular conditions.
Purpose of the Study:
- To evaluate the efficacy of DPI using low-dose rivaroxaban combined with antiplatelet therapy (APT) versus APT alone in preventing recurrent stroke in patients with sICAS.
Main Methods:
- A prospective cohort study involving 1217 patients with sICAS.
- Patients received either DPI (low-dose rivaroxaban + APT) or APT alone.
- Outcomes included ischemic stroke, TIA, ACS, and mortality within one year.
- Statistical analyses included Cox regression with IPTW and the win-ratio method for MACE.
Main Results:
- DPI therapy was associated with a significantly lower rate of ischemic stroke recurrence (6.1% vs. 12.5%) compared to APT alone.
- DPI significantly reduced the risk of recurrent ischemic stroke (HR=0.46) and major adverse cardiovascular events (MACE) (HR=0.53).
- Win-ratio analysis favored DPI for MACE (win ratio=2.34), with low rates of symptomatic intracranial hemorrhage and major bleeding events.
Conclusions:
- Dual pathway inhibition with low-dose rivaroxaban plus APT may decrease the risk of recurrent stroke in sICAS patients.
- These findings suggest DPI as a potential therapeutic option for sICAS, warranting further validation in large-scale randomized controlled trials.
Background:
The antithrombotic strategies for symptomatic intracranial atherosclerotic stenosis (sICAS) remains challenging. Dual pathway inhibition (DPI) has demonstrated clinical benefit in coronary and peripheral artery disease.
Aims:
This study aimed to evaluate the efficacy of DPI with low-dose rivaroxaban plus antiplatelet therapy (APT) compared with APT alone on recurrent stroke with sICAS.
Methods:
This prospective cohort study included patients with sICAS identified from the Ischemic Cerebrovascular Disease Database of the First Affiliated Hospital of Zhengzhou University between January 2019 to August 2023. Low-dose rivaroxaban was prescribed off-label to patients in the DPI group. The outcomes were ischemic stroke, transient ischemic attack (TIA), acute coronary syndrome (ACS), all-cause death and cardio-cerebrovascular death within 1 year of discharge. Cox regression with inverse probability of treatment weighting (IPTW) was applied to compare outcomes between the DPI and APT groups. The win-ratio method was used to assess the major adverse cardiovascular events (MACE), prioritized in the order of all-cause death, recurrent ischemic stroke or TIA, and ACS.
Results:
Among the 1217 patients with sICAS, 131 (10.8%) received DPI therapy. The recurrence rate of ischemic stroke was lower in the DPI group compared to the APT group (8/131 [6.1%] vs 136/1086 [12.5%]). DPI significantly reduced the risk of ischemic stroke recurrence (HR = 0.46, 95% CI: 0.23-0.94, p = 0.034) and the incidence of MACE (HR = 0.53, 95% CI: 0.29-0.97, p = 0.041) during the 1-year follow-up, consistent with the IPTW-based cohort (HR = 0.35, 95% CI: 0.16-0.76, p = 0.008; HR = 0.43, 95% CI: 0.22-0.83, p = 0.012). The win-ratio analysis of MACE favored DPI therapy (win ratio = 2.34, 95% CI: 1.41-3.90, p = 0.001). Symptomatic intracranial hemorrhage, fatal bleeding, and hospitalization for gastrointestinal bleeding were infrequent in this cohort.
Conclusions:
DPI therapy may be associated with a lower risk of recurrent stroke compared with antiplatelet therapy alone in patients with sICAS. These findings warrant further investigation through large-scale randomized controlled trials.
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