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Wang Y, Yuan T, Lyu T, Zhang L, Wang M, He Z, Wang Y, Li Z. Mechanism of inflammatory response and therapeutic effects of stem cells in ischemic stroke: current evidence and future perspectives. Neural Regen Res 2025; 20:67-81. [PMID: 38767477 PMCID: PMC11246135 DOI: 10.4103/1673-5374.393104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/13/2023] [Accepted: 11/21/2023] [Indexed: 05/22/2024] Open
Abstract
Ischemic stroke is a leading cause of death and disability worldwide, with an increasing trend and tendency for onset at a younger age. China, in particular, bears a high burden of stroke cases. In recent years, the inflammatory response after stroke has become a research hotspot: understanding the role of inflammatory response in tissue damage and repair following ischemic stroke is an important direction for its treatment. This review summarizes several major cells involved in the inflammatory response following ischemic stroke, including microglia, neutrophils, monocytes, lymphocytes, and astrocytes. Additionally, we have also highlighted the recent progress in various treatments for ischemic stroke, particularly in the field of stem cell therapy. Overall, understanding the complex interactions between inflammation and ischemic stroke can provide valuable insights for developing treatment strategies and improving patient outcomes. Stem cell therapy may potentially become an important component of ischemic stroke treatment.
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Affiliation(s)
- Yubo Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingli Yuan
- Shanghai Engineering Research Center of Stem Cells Translational Medicine, Shanghai, China
| | - Tianjie Lyu
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ling Zhang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Meng Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhiying He
- Shanghai Engineering Research Center of Stem Cells Translational Medicine, Shanghai, China
- Institute for Regenerative Medicine, Shanghai East Hospital, School of Life Sciences and Technology, Tongji University, Shanghai, China
| | - Yongjun Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Engineering Research Center of Digital Healthcare for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Engineering Research Center of Digital Healthcare for Neurological Diseases, Beijing, China
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Liu Q, Guo S, Wang N, Wang K, Mo S, Li X, Zhang Y, He H, Wang S, Wu J. Model based on single-nucleotide polymorphism to discriminate aspirin resistance patients. Stroke Vasc Neurol 2024; 9:212-220. [PMID: 37586776 PMCID: PMC11221311 DOI: 10.1136/svn-2022-002228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 07/30/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Aspirin is widely used for preventing ischaemic events. About 20%-40% of patients have aspirin resistance (ASR), which prevents them from benefiting from aspirin medication. This study aimed to develop and validate a model based on single-nucleotide polymorphism (SNP) to distinguish ASR patients. METHODS We included patients with spontaneous intracerebral haemorrhage and continuing antiplatelet therapy from a multicentre, prospective cohort study as the derivation cohort. Thromboelastography (inhibition of arachidonic acid channel<50%) was used to identify ASR. Genotyping was performed to identify the ASR-related SNP. Based on the result of the logistic analysis, the aspirin resistance in the Chinese population score (ASR-CN score) was established, and its accuracy was evaluated using the area under the curve (AUC). Patients receiving dual antiplatelet therapy for unruptured intracranial aneurysm embolism were prospectively included in the validation cohort. After embolism, 30-day ischaemic events, including ischaemic stroke, new or more frequent transient ischaemic attack, stent thrombosis and cerebrovascular death, were recorded. RESULTS The derivation cohort included 212 patients (155 male patients and the median age as 59). 87 (41.0%) individuals were identified with ASR. The multivariate logistic analysis demonstrated six SNPs of GP1BA, TBXA2R, PTGS2 and NOS3 as risk factors related to ASR. The ASR-CN score integrating these SNPs performed well to discriminate ASR patients from non-ASR patients (AUC as 0.77). Based on the validation cohort of 372 patients receiving antiplatelet therapy after embolism (including 130 ASR patients), the ASR-CN score continued to distinguish ASR patients with good accuracy (AUC as 0.80). Patients with high a ASR-CN score were more likely to suffer from 30-day ischaemic events after embolism (OR, 1.28; 95% CI, 1.10 to 1.50; p=0.002). CONCLUSION GP1BA, TBXA2R, PTGS2 and NOS3 were SNPs related to ASR. The ASR-CN score is an effective tool to discriminate ASR patients, which may guide antiplatelet therapy. CLINICAL TRIAL REGISTRATION Surgical Treatments of Antiplatelet Intracerebral Hemorrhage cohort (unique identifier: ChiCTR1900024406, http://www.chictr.org.cn/edit.aspx?pid=40640&htm=4).
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Affiliation(s)
- Qingyuan Liu
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Shuaiwei Guo
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Nuochuan Wang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Beijing, China
| | - Kaiwen Wang
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Shaohua Mo
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xiong Li
- Department of Neurosurgery, Beijing Chao-Yang Hospital Capital Medical University, Beijing, China
| | - Yanan Zhang
- Department of Blood Transfusion, Beijing Tiantan Hospital, Beijing, China
| | - Hongwei He
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
- Beijing Neurosurgical institution, Capital Medical University, Beijing, China
| | - Shuo Wang
- Beijing Neurosurgical institution, Capital Medical University, Beijing, China
| | - Jun Wu
- Department of Neurosurgery and China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
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Marinheiro G, Araújo B, Monteiro GDA, Leite M, Mutarelli A, Almeida AMD, Cavalcante-Neto JF, Rivera A, Pinheiro AC, Telles JPM. Ticagrelor versus clopidogrel in dual antiplatelet therapy after minor stroke or transient ischemic attack: an updated network meta-analysis. J Neurol 2024; 271:3030-3038. [PMID: 38580815 DOI: 10.1007/s00415-024-12330-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin is a well-established practice after a minor stroke or transient ischemic attack (TIA). However, ticagrelor plus aspirin may be an alternative. AIMS We systematically searched PubMed, Embase, and Cochrane Central from inception to January 2024. We included randomized controlled trials (RCTs) enrolling adults with acute minor stroke or TIA within 72 hours of the onset of the symptoms. RESULTS A total of 8 RCTs were included in our meta-analysis. Ticagrelor plus aspirin (RR, 0.70; 95% CrI 0.52, 0.91) and clopidogrel plus aspirin (RR, 0.79; 95% CrI 0.64, 0.98) were superior to aspirin in preventing stroke recurrence in overall analysis. Excluding studies with dual antiplatelet up to 90 days, ticagrelor plus aspirin was the only strategy that maintained superiority compared with aspirin regarding stroke recurrence (RR, 0.70; 95% CrI 0.51, 0.95) and ischemic stroke (RR, 0.68; 95% CrI 0.47, 0.94). There was no significant difference between treatment groups regarding hemorrhagic stroke, functional disability, and mortality. CONCLUSIONS DAPTs were superior to aspirin in preventing recurrence or ischemic stroke. Although no significant difference was observed between DAPTs, ticagrelor plus aspirin may be related to worse major bleeding results, including intracranial bleeding. Ticagrelor plus aspirin is a considerable option for patients after a minor stroke or TIA.
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Affiliation(s)
| | - Beatriz Araújo
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | | | - Marianna Leite
- School of Medicine, Santa Marcelina College, São Paulo, Brazil
| | - Antonio Mutarelli
- School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | - André Rivera
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | - Agostinho C Pinheiro
- Department of Neurology, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, USA
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Lim A, Ma H, Johnston SC, Singhal S, Muthusamy S, Wang Y, Pan Y, Coutts SB, Hill MD, Ois A, Kapral MK, Knoflach M, Woodhouse LJ, Bath PM, Phan TG. Ninety-Day Stroke Recurrence in Minor Stroke: Systematic Review and Meta-Analysis of Trials and Observational Studies. J Am Heart Assoc 2024; 13:e032471. [PMID: 38641856 PMCID: PMC11179866 DOI: 10.1161/jaha.123.032471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/18/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Risk of recurrence after minor ischemic stroke is usually reported with transient ischemic attack. No previous meta-analysis has focused on minor ischemic stroke alone. The objective was to evaluate the pooled proportion of 90-day stroke recurrence for minor ischemic stroke, defined as a National Institutes of Health Stroke Scale severity score of ≤5. METHODS AND RESULTS Published papers found on PubMed from 2000 to January 12, 2021, reference lists of relevant articles, and experts in the field were involved in identifying relevant studies. Randomized controlled trials and observational studies describing minor stroke cohort with reported 90-day stroke recurrence were selected by 2 independent reviewers. Altogether 14 of 432 (3.2%) studies met inclusion criteria. Multilevel random-effects meta-analysis was performed. A total of 6 randomized controlled trials and 8 observational studies totaling 45 462 patients were included. The pooled 90-day stroke recurrence was 8.6% (95% CI, 6.5-10.7), reducing by 0.60% (95% CI, 0.09-1.1; P=0.02) with each subsequent year of publication. Recurrence was lowest in dual antiplatelet trial arms (6.3%, 95% CI, 4.5-8.0) when compared with non-dual antiplatelet trial arms (7.2%, 95% CI, 4.7-9.6) and observational studies 10.6% (95% CI, 7.0-14.2). Age, hypertension, diabetes, ischemic heart disease, or known atrial fibrillation had no significant association with outcome. Defining minor stroke with a lower National Institutes of Health Stroke Scale threshold made no difference - score ≤3: 8.6% (95% CI, 6.0-11.1), score ≤4: 8.4% (95% CI, 6.1-10.6), as did excluding studies with n<500%-7.3% (95% CI, 5.5-9.0). CONCLUSIONS The risk of recurrence after minor ischemic stroke is declining over time but remains important.
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Affiliation(s)
- Andy Lim
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
- Department of Emergency MedicineMonash HealthMelbourneVictoriaAustralia
| | - Henry Ma
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
- Department of NeurologyMonash HealthMelbourneVictoriaAustralia
| | | | - Shaloo Singhal
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
- Department of NeurologyMonash HealthMelbourneVictoriaAustralia
| | - Subramanian Muthusamy
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
- Department of NeurologyMonash HealthMelbourneVictoriaAustralia
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Centre for Neurological DiseasesBeijingChina
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Centre for Neurological DiseasesBeijingChina
| | - Shelagh B. Coutts
- Department of Clinical Neurosciences, Radiology and Community Health SciencesHotchkiss Brain Institute, University of CalgaryAlbertaCanada
| | - Michael D. Hill
- Department of Clinical Neurosciences, Radiology and Community Health SciencesHotchkiss Brain Institute, University of CalgaryAlbertaCanada
| | - Angel Ois
- Servicio de Neurologı’a, Hospital del MarBarcelonaSpain
| | | | - Michael Knoflach
- Department of NeurologyInnsbruck Medical UniversityInnsbruckAustria
| | - Lisa J. Woodhouse
- Stroke Trials Unit, Mental Health & Clinical NeuroscienceUniversity of Nottingham, Queen’s Medical CentreNottinghamUnited Kingdom
| | - Philip M. Bath
- Stroke Trials Unit, Mental Health & Clinical NeuroscienceUniversity of Nottingham, Queen’s Medical CentreNottinghamUnited Kingdom
| | - Thanh G. Phan
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
- Department of NeurologyMonash HealthMelbourneVictoriaAustralia
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Lim A, Ma H, Ly J, Singhal S, Pan Y, Wang Y, Johnston SC, Phan TG. Comparison of Dual Antiplatelet Therapies for Minor, Nondisabling, Acute Ischemic Stroke: A Bayesian Network Meta-Analysis. JAMA Netw Open 2024; 7:e2411735. [PMID: 38753327 PMCID: PMC11099682 DOI: 10.1001/jamanetworkopen.2024.11735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/15/2024] [Indexed: 05/19/2024] Open
Abstract
Importance Dual antiplatelet therapy (DAPT) appears to be an effective treatment option for minor (nondisabling) acute ischemic stroke. This conclusion is based on trials that include both transient ischemic attack (TIA) and minor stroke; however, these 2 conditions may differ. Objective To compare DAPT regimens specifically for minor stroke. Data Sources PubMed was searched for randomized clinical trials published up to November 4, 2023. Search terms strategy included TIA, transient ischemic attack, minor stroke, or moderate stroke, with the filter randomized controlled trial. Unpublished data on minor stroke were sourced from authors and/or institutions. Study Selection Trials testing DAPT within the first 24 hours of a minor stroke (defined as a National Institutes of Health Stroke Scale score ≤5) were included by consensus. Of 1508 studies screened, 6 (0.3%) initially met inclusion criteria and were reviewed. Data Extraction and Synthesis The study was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines by multiple observers. Bayesian fixed-effect network meta-analysis was conducted. Secondary analysis performed for high-risk TIA alone. Main Outcomes and Measures Treatments were ranked using a probability measure called surface under the cumulative rank curve (SUCRA). The primary outcome was subsequent ischemic stroke at 90 days. Secondary outcomes included major hemorrhage, mortality, and hemorrhagic stroke. The number needed to treat (NNT) and number needed to harm (NNH) were obtained. Results Five trials were included that described 28 148 patients, of whom 22 203 (78.9%) had a minor stroke. Of these, 13 995 (63.0%) were in DAPT groups and 8208 (37.0%) in aspirin (acetylsalicylic acid) groups. Aspirin and ticagrelor had a 94% probability of being the superior treatment for minor stroke (SUCRA, 0.94) for the primary outcome. Both aspirin and ticagrelor (NNT, 40; 95% CI, 31-64) and aspirin and clopidogrel (NNT, 58; 95% CI, 39-136) were superior to aspirin alone in the prevention of recurrent ischemic stroke at 90 days. Both treatments had higher rates of major hemorrhage than aspirin alone (NNH for aspirin and ticagrelor, 284; 95% CI, 108-1715 vs NNH for aspirin and clopidogrel, 330; 95% CI, 118-3430), but neither had increased risk of hemorrhagic stroke or death. For high-risk TIA, ticagrelor and aspirin had a 60% probability (SUCRA, 0.60) and clopidogrel and aspirin had a 40% probability (SUCRA 0.40) of being a superior treatment; neither was optimum, but both were superior to aspirin alone for the primary outcome. Conclusions and Relevance These findings suggest that DAPT with aspirin and ticagrelor has higher probability of being the superior treatment among patients with minor stroke when presence of CYP2C19 loss-of-function alleles has not been excluded. For patients with TIA, the superiority of aspirin and ticagrelor vs aspirin and clopidogrel was not demonstrated.
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Affiliation(s)
- Andy Lim
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Emergency Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Henry Ma
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Division of Clinical Trials, Imaging, and Informatics, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia (SM)
| | - John Ly
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Shaloo Singhal
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Division of Clinical Trials, Imaging, and Informatics, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia (SM)
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | | | - Thanh G. Phan
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Division of Clinical Trials, Imaging, and Informatics, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia (SM)
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Biswas M, Hossain MS, Ahmed Rupok T, Hossain MS, Sukasem C. The association of CYP2C19 LoF alleles with adverse clinical outcomes in stroke patients taking clopidogrel: An updated meta-analysis. Clin Transl Sci 2024; 17:e13792. [PMID: 38581109 PMCID: PMC10997845 DOI: 10.1111/cts.13792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/11/2024] [Accepted: 03/15/2024] [Indexed: 04/08/2024] Open
Abstract
The aggregated risk of recurrent stroke in stroke/transient ischemic attack (TIA) patients carrying CYP2C19 LoF alleles who take clopidogrel has not been investigated recently, and the available research is limited. This study aimed to perform an updated meta-analysis to assess the association between CYP2C19 LoF alleles and the risk of recurrent stroke in patients taking clopidogrel. Databases were searched for the literature on eligible studies. The end points were recurrent stroke, composite vascular events, and bleeding events. Odds ratios (ORs) were calculated using RevMan software, where p < 0.05 was considered statistically significant. Patients carrying CYP2C19 LoF alleles who were treated with clopidogrel had a significantly increased risk of recurrent ischemic stroke compared with non-carriers (OR 2.18, 96% CI 1.80-2.63; p < 0.00001). The risk of recurrent stroke was only significantly different in Asian patients (OR 2.29, 96% CI 1.88-2.80; p < 0.00001) but not in patients of other ethnicities; however, there were a limited number of studies in other ethnic groups. Both observational studies (OR 2.83, 96% CI 2.20-3.65; p < 0.00001) and RCTs (OR 1.48, 96% CI 1.10-1.98; p = 0.009) found associations with a significantly increased risk of recurrent ischemic stroke. Asian stroke patients or TIA patients carrying CYP2C19 LoF alleles and taking clopidogrel were at a significantly higher risk of recurrent ischemic stroke than non-carriers. Significantly increased risk of recurrent ischemic stroke was found in both observational studies and RCTs.
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Affiliation(s)
- Mohitosh Biswas
- Department of PharmacyUniversity of RajshahiRajshahiBangladesh
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC)Ramathibodi HospitalBangkokThailand
| | | | | | | | - Chonlaphat Sukasem
- Division of Pharmacogenomics and Personalized Medicine, Department of Pathology, Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
- Laboratory for Pharmacogenomics, Somdech Phra Debaratana Medical Center (SDMC)Ramathibodi HospitalBangkokThailand
- Pharmacogenomics and Precision Medicine, The Preventive Genomics & Family Check‐up Services Center, Bumrungrad International HospitalBangkokThailand
- Faculty of Pharmaceutical SciencesBurapha UniversitySaensuk, MueangChonburiThailand
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Chen W, Wang Y, Jiang L, Wang Y, Wang Y. New Drug Developments for Stroke: from Basics to Clinics. Transl Stroke Res 2024; 15:335-338. [PMID: 36740639 DOI: 10.1007/s12975-023-01130-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 02/07/2023]
Affiliation(s)
- Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yicong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lingling Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China.
- Chinese Institute for Brain Research, Beijing, China.
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Ip BYM, Ko H, Lam BYK, Au LWC, Lau AYL, Huang J, Kwok AJ, Leng X, Cai Y, Leung TWH, Mok VCT. Current and Future Treatments of Vascular Cognitive Impairment. Stroke 2024; 55:822-839. [PMID: 38527144 DOI: 10.1161/strokeaha.123.044174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Affiliation(s)
- Bonaventure Yiu Ming Ip
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
- Kwok Tak Seng Centre for Stroke Research and Intervention, Hong Kong SAR, China (B.Y.M.I., X.L., T.W.H.L.)
| | - Ho Ko
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Bonnie Yin Ka Lam
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Lisa Wing Chi Au
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Alexander Yuk Lun Lau
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
| | - Junzhe Huang
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Andrew John Kwok
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Xinyi Leng
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Kwok Tak Seng Centre for Stroke Research and Intervention, Hong Kong SAR, China (B.Y.M.I., X.L., T.W.H.L.)
| | - Yuan Cai
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Thomas Wai Hong Leung
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Kwok Tak Seng Centre for Stroke Research and Intervention, Hong Kong SAR, China (B.Y.M.I., X.L., T.W.H.L.)
| | - Vincent Chung Tong Mok
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
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9
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Zhou Y, Zhou Y. Non-adaptive cognitive emotion regulation mediates the relationship between disease uncertainty and acute stress disorder in patients with ischaemic stroke. Front Psychiatry 2024; 15:1319848. [PMID: 38510806 PMCID: PMC10952823 DOI: 10.3389/fpsyt.2024.1319848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/20/2024] [Indexed: 03/22/2024] Open
Abstract
Background During epidemic outbreaks, hospitalized patients, especially those with cerebrovascular disease, were identified as a vulnerable group suffering from acute stress disorder (ASD) and consequent psychological distress. For stroke patients, not only will they suffer from physical illness, but the uncertainty of illness caused by sudden illness may also cause patients to experience different degrees of ASD. Relevant studies have shown that the impact of ASD on individuals may vary according to age, gender, disease characteristics, individual personality, treatment methods, income level, family support, cognitive psychology and other factors. However, non-adaptive cognitive emotion regulation plays a crucial role in influencing individual psychological states. At present, the risk factors of ASD after stroke and the mechanism between illness uncertainty and cognitive emotion regulation are not fully understood. Therefore, we focus on exploring the predictive effects of general demographic and disease-related characteristics, maladaptive cognitive emotion regulation, and illness uncertainty on ASD after stroke, and make hypotheses. When a disease acts on the body, the patient will have the corresponding cognition of the disease, and ASD will appear at the same time. Then the maladaptive cognitive emotion regulation as an important mediating variable can aggravate the level of acute stress disorder and be verified. Methods We used a cross-sectional design, which can be used to investigate the distribution of a disease or health condition and its related factors in a specific population at a specific time, so as to describe the distribution of the disease or health condition and its relationship with related factors. A total of 256 hospitalized patients with ischemic stroke were enrolled, including 145 males and 111 females, aged from 26 to 90 years, with a mean age of (64.71 ± 12.20) years. All patients completed and returned a self-report questionnaire that included demographic information, illness uncertainty, cognitive emotion regulation, and ASD. We then compared the differences in general demographic data, illness uncertainty, and maladaptive cognitive emotion regulation in acute stress disorders. Results The majority of hospitalized stroke patients (67.6%) developed ASD due to the COVID-19 pandemic and were therefore at risk for PTSD. More than one third (39.1%) of stroke survivors also suffered from severe psychological distress. More specifically, younger stroke patients are more likely to experience ASD than older patients. Although higher illness uncertainty scores indicate more severe ASD, adaptive cognitive emotion regulation was a protective factor. Conclusion Given that individuals with ASD are susceptible to PTSD, it is critical to follow up hospitalized patients with ischemic stroke for screening for PTSD and referral to appropriate psychological services. Maladaptive cognitive emotion regulation can increase the impact of uncertainty on the traumatic experience of stroke patients. Therefore, health care institutions should increase their efforts to provide psychosocial support services to hospitalized patients and make continuous efforts to screen for symptoms of trauma and psychological distress in hospitalized stroke patients.
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Affiliation(s)
- Yanan Zhou
- School of Nursing, Qingdao Binhai University, Qingdao, Shandong, China
| | - Yani Zhou
- The department of breast and thyroid, Zhongshan Hospital Affiliated to Dalian University, Dalian, Liaoning, China
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10
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Cheng A, Xue J, Wang A, Xu Q, Feng Z, Lin J, Li H, Meng X, Xu J, Wang Y. LDL-C Levels and Bleeding Risk in Patients Taking DAPT After Minor Ischemic Stroke or TIA. JAMA Neurol 2024:2815831. [PMID: 38436990 PMCID: PMC10913006 DOI: 10.1001/jamaneurol.2024.0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/05/2024] [Indexed: 03/05/2024]
Abstract
Importance Evidence on the bleeding risk associated with low-density lipoprotein cholesterol (LDL-C) levels in patients receiving dual antiplatelet therapy (DAPT) remains sparse. Objective To investigate the association of LDL-C levels with bleeding risk in patients with minor ischemic stroke (MIS) or high-risk transient ischemic attack (HRTIA) receiving DAPT. Design, Setting, and Participants This cohort study was an analysis of pooled data from 2 randomized, double-blind, placebo-controlled clinical trials in China of patients with MIS or HRTIA who were receiving DAPT: the CHANCE (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events) trial enrolled patients at 114 sites from October 2009 to July 2012, and the CHANCE-2 enrolled patients at 202 centers from September 2019 to March 2021. Both sets of patients were followed up for 90 days. Data analysis was performed from August 2022 to May 2023. Exposures Baseline LDL-C levels and receipt of ticagrelor-aspirin and clopidogrel-aspirin DAPT. Main Outcomes and Measures The primary outcome was any bleeding, and the secondary outcome was severe or moderate bleeding within 3 months after randomization. The association of LDL-C levels and all outcomes was assessed by using the Cox proportional hazard model. Hazard ratios (HRs) with 95% CIs were calculated on univariable (unadjusted) Cox regression models. Adjusted HRs (aHRs) and their 95% CIs were calculated on multivariable Cox regression models. Results In total, 8996 patients with acute MIS or HRTIA who were receiving DAPT were included in the 2 trials, of whom 1066 without serum specimens and 490 patients with missing baseline LDL-C value were excluded. Finally, 7440 patients with DAPT (4486 in the clopidogrel-aspirin group and 2954 in the ticagrelor-aspirin group) were included in this study. The median (IQR) age was 64.32 (56.56-71.30) years, and 2479 patients (33.32%) were women. A total of 270 (3.63%) bleeding events were reported at 3 months, and LDL-C less than 70 mg/dL was associated with an increased risk of both any bleeding (aHR, 1.48; 95% CI, 1.03-2.12), and severe or moderate bleeding (aHR, 2.78; 95% CI, 1.18-6.53). The risk of any bleeding was increased at lower LDL-C levels in the ticagrelor-aspirin group (aHR, 1.71; 95% CI, 1.08-2.72). However, an increased risk of any bleeding was not observed in the clopidogrel-aspirin group (aHR, 1.30; 95% CI, 0.73-2.30). There was no significant association between LDL-C levels and the risk of severe or moderate bleeding in either the ticagrelor-aspirin or clopidogrel-aspirin group. Conclusions and Relevance These findings suggest that low LDL-C levels are associated with an increased bleeding risk within 3 months among patients with MIS or HRTIA receiving DAPT, especially those taking ticagrelor-aspirin. Weighing the risks and benefits is crucial when simultaneously considering the selection of LDL-C target strategies and DAPT regimens among these patients.
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Affiliation(s)
- Aichun Cheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Xue
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qin Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhiyuan Feng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
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11
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Wang A, Tian X, Xie X, Li H, Bath PM, Jing J, Lin J, Wang Y, Zhao X, Li Z, Liu L, Wang Y, Meng X. Differential effect of ticagrelor versus clopidogrel by homocysteine levels on risk of recurrent stroke: a post hoc analysis of the CHANCE-2 trial. CMAJ 2024; 196:E149-E156. [PMID: 38346785 PMCID: PMC10861269 DOI: 10.1503/cmaj.231262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Elevated homocysteine levels are associated with increased blood coagulation and platelet activity and may modulate the response to antiplatelet therapies. We aimed to investigate the effects of homocysteine levels on the efficacy and safety of ticagrelor-acetylsalicylic acid (ASA) versus clopidogrel-ASA among patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles. METHODS We conducted a post hoc analysis of the CHANCE-2 (The Clopidogrel in High-risk Patients with Acute Nondisabling Cerebrovascular Events-II) trial. Participants were randomly assigned to treatment with ticagrelor-ASA or clopidogrel-ASA. We categorized participants into groups with elevated and non-elevated homocysteine levels, based on the median level. The primary efficacy outcome was recurrent stroke within 90-day follow-up. The primary safety outcome was severe or moderate bleeding within 90 days. RESULTS A total of 2740 participants were randomly assigned to receive ticagrelor-ASA and 2700 to receive clopidogrel-ASA. Use of ticagrelor-ASA was associated with a reduced risk of recurrent stroke among participants with elevated homocysteine levels (74 [5.3%] v. 119 [8.5%]; hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.45-0.81), but not among those with non-elevated levels (86 [6.4%] v. 87 [6.7%]; HR 0.97, 95% CI 0.71-1.32; p = 0.04 for interaction). When analyzed as a continuous variable, the benefits of ticagrelor-ASA with regard to recurrent stroke increased as homocysteine levels increased (p = 0.04 for interaction). No significant interaction between homocysteine levels and treatment with regard to severe or moderate bleeding was observed (p = 0.7 for interaction). We found a significant interaction between homocysteine levels and therapy with regard to recurrent stroke in females (p = 0.04 for interaction) but not males. INTERPRETATION In comparison with clopidogrel-ASA, ticagrelor-ASA conferred more benefit to patients with elevated homocysteine levels, particularly to female patients, in this secondary analysis of a randomized controlled trial involving patients with minor ischemic stroke or TIA. TRIAL REGISTRATION ClinicalTrials.gov, no. NCT04078737.
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Affiliation(s)
- Anxin Wang
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xue Tian
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuewei Xie
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Philip M Bath
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxi Lin
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases (A. Wang, Tian, Xie, H. Li, Jing, Lin, Yilong Wang, Zhao, Z. Li, Liu, Yongjun Wang, Meng), Beijing, China; Beijing Municipal Key Laboratory of Clinical Epidemiology (A. Wang), Beijing, China; Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University, Beijing, China; Stroke Trials Unit, Mental Health and Clinical Neuroscience (Bath), University of Nottingham, Nottingham, UK; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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12
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Tan Q, Yang L, Yuan S, Zheng D, Lin Y, Chen K, He Y, Chen S, Hao J, Dai J, He S, Mao F, Leng X, Jiang H, Yang J. METTL3-mediated methylation of CYP2C19 mRNA may aggravate clopidogrel resistance in ischemic stroke patients. Open Med (Wars) 2024; 19:20240899. [PMID: 38463525 PMCID: PMC10921439 DOI: 10.1515/med-2024-0899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 12/01/2023] [Accepted: 12/15/2023] [Indexed: 03/12/2024] Open
Abstract
Background N6-methyladenosine (m6A) is the most frequently occurring interior modification in eukaryotic messenger RNA (mRNA), and abnormal mRNA modifications can affect many biological processes. However, m6A's effect on the metabolism of antiplatelet drugs for the prevention of ischemic stroke (IS) remains largely unclear. Methods We analyzed the m6A enzymes and m6A methylation in peripheral blood samples of IS patients with/without clopidogrel resistance (CR), and the peripheral blood and liver of rat models with/without CR. We also compared the effect of m6A methylation on the expression of the drug-metabolizing enzymes (CYP2C19 and CYP2C6v1) in CR and non-CR samples. Results Methyltransferase-like 3 (METTL3), an m6A enzyme, was highly expressed in the peripheral blood of patients with CR, and in both the peripheral blood and liver of rats with CR. This enzyme targets CYP2C19 or CYP2C6v1 mRNA through m6A methylation, resulting in low expression of CYP2C19 or CYP2C6v1 mRNA. Consequently, this leads to decreased clopidogrel metabolism and CR. Conclusion The METTL3-mediated methylation of CYP2C19 mRNA may aggravate CR in IS patients.
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Affiliation(s)
- Quandan Tan
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Le Yang
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- Department of Neurology, The Second Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Shanshan Yuan
- Department of Critical Care Medicine, The General Hospital of Western Theater Command, Chengdu, China
| | - Danni Zheng
- Biomedical Informatics and Digital Health, School of Medical Sciences, University of Sydney, Sydney, Australia
| | - Yapeng Lin
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
- International Clinical Research Center, Chengdu Medical College, Chengdu, China
| | - Kejie Chen
- School of Public Health, Chengdu Medical College, Chengdu, China
| | - Ying He
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Shuntian Chen
- School of Biomedical Sciences and Technology, Chengdu Medical College, Chengdu, China
| | - Junli Hao
- School of Biomedical Sciences and Technology, Chengdu Medical College, Chengdu, China
| | - Jin Dai
- School of Biomedical Sciences and Technology, Chengdu Medical College, Chengdu, China
| | - Song He
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Fengkai Mao
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Xinyi Leng
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Haisong Jiang
- Department of Neurology, Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Jie Yang
- Department of Neurology, Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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13
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Wabnitz AM, Turan TN. Optimal Medical Management of Atherosclerotic Intracranial Stenosis. Stroke 2024; 55:335-343. [PMID: 38252762 DOI: 10.1161/strokeaha.123.043633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Reducing the high risk of recurrent stroke in patients with symptomatic intracranial atherosclerotic stenosis (sICAS) has proven to be challenging, but aggressive medical management, with intensive risk factor control and antithrombotic therapy, has been shown to be beneficial. High-intensity statins are recommended for patients with atherosclerotic stroke, including sICAS. Ezetimibe and PCSK9 (proprotein convertase subtilisin/kexin type 9) inhibitors are beneficial for those who fail to reach low-density lipoprotein targets or those with statin intolerance. The treatment target for sICAS is low-density lipoprotein <70 mg/dL. In neurologically stable patients, blood pressure should be treated to goal <140/90 mm Hg with the use of thiazide diuretics, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers preferentially. For those with diabetes, treat to goal hemoglobin A1C ≤7% for most patients through combination of diet, insulin, and hypoglycemic drugs. Some degree of physical activity (eg, walking, stationary biking with arms or legs, etc) should be encouraged in all patients with sICAS who are not severely disabled. A minimum of 10 minutes of moderate-intensity aerobic activity 4 times a week is recommended for patients who are capable of exercise. For all patients with severe sICAS (70%-99% stenosis), dual antiplatelet therapy for up to 90 days followed by single antiplatelet agent is recommended.
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Affiliation(s)
- Ashley M Wabnitz
- Department of Neurology, Medical University of South Carolina, Charleston
| | - Tanya N Turan
- Department of Neurology, Medical University of South Carolina, Charleston
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14
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Chan BPL, Wong LYH, Tan BYQ, Yeo LLL, Venketasubramanian N. Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review. J Cardiovasc Dev Dis 2024; 11:48. [PMID: 38392262 PMCID: PMC10889184 DOI: 10.3390/jcdd11020048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.
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Affiliation(s)
- Bernard P L Chan
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Lily Y H Wong
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Leonard L L Yeo
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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15
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Liu L, Li Z, Zhou H, Duan W, Huo X, Xu W, Li S, Nie X, Liu H, Liu J, Sun D, Wei Y, Zhang G, Yuan W, Zheng L, Liu J, Wang D, Miao Z, Wang Y. Chinese Stroke Association guidelines for clinical management of ischaemic cerebrovascular diseases: executive summary and 2023 update. Stroke Vasc Neurol 2023; 8:e3. [PMID: 38158224 PMCID: PMC10800268 DOI: 10.1136/svn-2023-002998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/23/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND China is one of the countries with the highest burden of stroke. Implementing multidimensional management guidelines will help clinicians practise evidence-based care, improve patient outcomes and alleviate societal burdens. This update of the 2019 edition will provide the latest comprehensive recommendations for the diagnosis and treatment of ischaemic cerebrovascular diseases. METHODS We conducted a comprehensive search on MEDLINE (via PubMed) up to 31 August 2023. The writing team established the recommendations through multiple rounds of online and offline discussions. Each recommendation was graded using the evidence grading algorithm developed by the Chinese Stroke Association (CSA). The draft was reviewed and finalised by the CSA Stroke Guidelines Writing Committee. RESULTS This update included revisions of 15 existing recommendations and 136 new recommendations in the following areas of stroke care: emergency assessment and diagnosis of ischaemic cerebrovascular disease, acute-phase reperfusion therapy, evaluation of underlying mechanisms, antithrombotic therapy, prevention and treatment of complications, and risk factor management. CONCLUSIONS This guideline updated the recommendations for the clinical management of ischaemic cerebrovascular disease from 2019.
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Affiliation(s)
- Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
| | - Hongyu Zhou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wanying Duan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Neurological Disease Center, Cerebral Vascular Disease Department, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Weihai Xu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shujuan Li
- Department of Neurology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Huihui Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, the Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jinjie Liu
- Department of General Medicine, Dalian Municipal Central Hospital Affiliated Dalian University of Technology, Dalian, China
| | - Dapeng Sun
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yufei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Guitao Zhang
- Department of Neurology, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weizhuang Yuan
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lina Zheng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Zhongrong Miao
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China
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16
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Wang C, Jia W, Jing J, Meng X, Wang A, Xu Q, Zhang X, Pan Y, Xie X, Johnston SC, Bath PM, Lin J, Jiang Y, Li H, Wang Y, Zhao X, Liu L, Li Z, Wang Y. Ticagrelor Versus Clopidogrel in Minor Stroke or Transient Ischemic Attack With Intracranial Artery Stenosis: A Post Hoc Analysis of CHANCE-2. J Am Heart Assoc 2023; 12:e031611. [PMID: 37889172 PMCID: PMC10727397 DOI: 10.1161/jaha.123.031611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
Background This study aimed to investigate the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in Chinese patients by the presence and clinical presentation of intracranial artery stenosis (ICAS) using randomized trial data from the CHANCE-2 (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II) trial. Methods and Results A total of 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles were randomized to either the ticagrelor-aspirin or clopidogrel-aspirin group. Patients without imaging of the intracranial artery were excluded from the nonprespecified subgroup analysis of CHANCE-2. All patients included were classified into the following groups: without ICAS, symptomatic ICAS, or asymptomatic ICAS. The primary efficacy outcome was new strokes within 90 days. There were 5893 patients (median age, 64.8 years; 33.9% women) included, and 172 (4.9%), 171 (10.5%), and 57 (7.7%) cases of new strokes occurred within 90 days in the without ICAS, with symptomatic ICAS, and with asymptomatic ICAS groups, respectively. Ticagrelor-aspirin was associated with reduced risk of new stroke in patients without ICAS (62 [3.5%] versus 110 [6.3%]; hazard ratio [HR], 0.57 [95% CI, 0.41-0.78]) but not in those with symptomatic ICAS (HR, 0.77 [95% CI, 0.56-1.05]) or in those with asymptomatic ICAS (HR, 0.77 [95% CI, 0.43-1.38]) compared with clopidogrel-aspirin (P for interaction=0.14). There were no significant differences in the proportion of severe or moderate bleeding events among different ICAS groups. Conclusions Patients without ICAS received a significantly greater benefit from ticagrelor-aspirin than clopidogrel-aspirin after minor ischemic stroke or transient ischemic attack, and there was no statistically significant difference between treatments in patients with symptomatic ICAS or asymptomatic ICAS. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04078737.
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Affiliation(s)
- Chunjuan Wang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical SciencesBeijingChina
- National Center for Healthcare Quality Management in Neurological DiseasesBeijingChina
| | - Weili Jia
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Jing Jing
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xia Meng
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Anxin Wang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Qin Xu
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xinmiao Zhang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yuesong Pan
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xuewei Xie
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | | | - Philip M. Bath
- Stroke Trials Unit, Division of Clinical NeuroscienceUniversity of NottinghamNottinghamUnited Kingdom
| | - Jinxi Lin
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yong Jiang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Hao Li
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Yilong Wang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xingquan Zhao
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Liping Liu
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Zixiao Li
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical SciencesBeijingChina
- National Center for Healthcare Quality Management in Neurological DiseasesBeijingChina
- Chinese Institute for Brain ResearchBeijingChina
| | - Yongjun Wang
- Vascular Neurology, Department of NeurologyBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
- Advanced Innovation Center for Human Brain ProtectionCapital Medical UniversityBeijingChina
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical SciencesBeijingChina
- Chinese Institute for Brain ResearchBeijingChina
- Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of SciencesShanghaiChina
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17
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Tan H. The mediating role of anxiety in disease uncertainty and acute stress in acute ischaemic stroke patients in the post-epidemic era. Front Psychiatry 2023; 14:1218390. [PMID: 37915800 PMCID: PMC10616834 DOI: 10.3389/fpsyt.2023.1218390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/01/2023] [Indexed: 11/03/2023] Open
Abstract
Objective To analyse the influencing factors of anxiety, disease uncertainty and acute stress response in patients with acute ischaemic stroke, and to verify the mediating role of anxiety in the post-epidemic era. Methods 240 patients with acute ischaemic stroke were selected from a tertiary hospital in Wuhan City and investigated by questionnaire and convenience sampling methods. Results The total anxiety score, disease uncertainty and acute stress reaction were at moderate levels. Anxiety was positively correlated with illness uncertainty, and anxiety and acute stress response were negatively correlated. Multiple linear regression analysis showed that Sickness uncertainty, acute stress response, age, and work status influenced anxiety. Anxiety mediated the prediction of Sickness uncertainty and acute stress response, with the mediating effect accounting for 35.6% of the total effect. Conclusion Disease uncertainty in patients with acute ischaemic stroke in the post-epidemic era directly affects the acute stress response and indirectly through anxiety.
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Affiliation(s)
- Hui Tan
- Quzhou TCM Hospital at the Junction of Four Provinces Affiliated to Zhejiang Chinese Medical University/Quzhou Hospital of Traditional Chinese Medicine, Quzhou, China
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18
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Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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Xu Y, Yao D, Chen W, Yan H, Zhao D, Jiang L, Wang Y, Zhao X, Liu L, Wang Y, Pan Y, Wang Y. Using the PEAR1 Polymorphisms Rs12041331 and Rs2768759 as Potential Predictive Markers of 90-Day Bleeding Events in the Context of Minor Strokes and Transient Ischemic Attack. Brain Sci 2023; 13:1404. [PMID: 37891772 PMCID: PMC10605279 DOI: 10.3390/brainsci13101404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/22/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
In this study, we explored the relationship between the platelet endothelial aggregation receptor 1 (PEAR1) polymorphisms, platelet reactivity, and clinical outcomes in patients with minor stroke or transient ischemic attack (TIA). Randomized controlled trial subgroups were assessed, wherein patients received dual antiplatelet therapy for at least 21 days. Platelet reactivity was measured at different time intervals. Genotypes were categorized as wild-type, mutant heterozygous, and mutant homozygous. Clinical outcomes were evaluated after 90 days. The rs12041331 polymorphism predominantly influenced adenosine diphosphate channel platelet activity, with the AA genotype displaying significantly lower residual platelet activity to the P2Y12 response unit (p < 0.01). This effect was more evident after 7 days of dual antiplatelet treatment (p = 0.016). Mutant A allele carriers had decreased rates of recurrent stroke and complex endpoint events but were more prone to bleeding (p = 0.015). The rs2768759 polymorphism majorly impacted arachidonic acid (AA) channel platelet activity, which was particularly noticeable in the C allele carriers. Our regression analysis demonstrated that rs12041331 AA + GA and rs2768759 CA predicted 90-day post-stroke bleeding. In conclusion, the PEAR1 polymorphisms rs12041331 and rs2768759 interfere with platelet aggregation and the performance of antiplatelet drugs. These genetic variations may contribute to bleeding events associated with minor stroke and TIA.
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Affiliation(s)
- Yanjie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
- Department of Neurology, Beijing Long Fu Hospital, Beijing 100010, China
| | - Dongxiao Yao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
| | - Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
| | - Dexiu Zhao
- Department of Neurology, Aviation General Hospital, Beijing 100025, China;
| | - Lingling Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
| | - Yicong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100069, China; (Y.X.); (Y.W.)
- China National Clinical Research Center for Neurological Diseases, Beijing 100070, China
- Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing 100050, China
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Xie X, Jing J, Meng X, Claiborne Johnston S, Bath PM, Li Z, Zhao X, Liu L, Wang Y, Xu Q, Wang A, Jiang Y, Li H, Wang Y. Dual Antiplatelet Therapies and Causes in Minor Stroke or Transient Ischemic Attack: A Prespecified Analysis in the CHANCE-2 Trial. Stroke 2023; 54:2241-2250. [PMID: 37548009 DOI: 10.1161/strokeaha.122.042233] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/25/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND It is unclear whether patients with different stroke/transient ischemic attack etiologies benefit differently from gene-directed dual antiplatelet therapy. This study explored the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in transient ischemic attack or minor stroke with different causes in the CHANCE-2 trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II). METHODS This was a prespecified analysis of the CHANCE-2 trial, which enrolled 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles. Patients with centralized evaluation of TOAST (Trial of ORG 10172 in Acute Stroke Treatment) classification of large-artery atherosclerosis, small-vessel occlusion, and stroke of undetermined cause were included. The primary efficacy outcome was new stroke, and the primary safety outcome was severe or moderate bleeding, both within 90 days. Cox proportional hazards models were used to assess the interaction of TOAST classification with the effects of dual antiplatelet therapy with ticagrelor-aspirin versus clopidogrel-aspirin. RESULTS A total of 6336 patients were included in this study. In patients administered ticagrelor-aspirin and clopidogrel-aspirin, respectively, stroke recurred in 85 (9.8%) and 88 (10.7%) patients with large-artery atherosclerosis (hazard ratio, 0.86 [95% CI, 0.63-1.18]; P=0.34); 32 (3.6%) and 61 (7.0%) patients with small-vessel occlusion (hazard ratio, 0.51 [95% CI, 0.33-0.79]; P=0.002); and 68 (4.8%) and 87 (5.9%) patients with stroke of undetermined cause (hazard ratio, 0.80 [95% CI, 0.58-1.10]; P=0.17), with P=0.08 for the treatment×cause subtype interaction effect. There were no significant differences in severe or moderate bleeding events in patients with different cause and different treatment. CONCLUSIONS In this prespecified analysis of the CHANCE-2 trial, the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in preventing new stroke were consistent in patients with different causes. The influence of stroke cause on benefit of gene-guided antiplatelet therapy should be explored by further trials. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04078737.
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Affiliation(s)
- Xuewei Xie
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Jing Jing
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Tiantan Neuroimaging Center of Excellence, Beijing, China (J.J.)
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | | | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
| | - Zixiao Li
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Xingquan Zhao
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Liping Liu
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Qin Xu
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Yong Jiang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China (X.X., J.J., X.M., Z.L., X.Z., L.L., Yilong Wang, Q.X., A.W., Y.J., H.L., Yongjun Wang)
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Li T, Song C, Liebeskind DS, Dmytriw AA, Xu R, Wang X, Wang J, Zhao H, Cao W, Gong H, Zhang C, Bai X, Jiao L. Clinical evidence in ischemic stroke: Where we have gone so far and hopes for the future. Eur J Neurol 2023. [PMID: 37650337 DOI: 10.1111/ene.16047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE Ischemic stroke is a significant cause of disability and death worldwide. Randomized clinical trials (RCTs) are important in changing guidelines and treatment strategies. This study aimed to analyze the progress of RCTs in ischemic stroke and to guide future research directions. METHODS Ischemic stroke-related RCT articles were identified in six high-impact medical journals using the Web of Science Core Collection database. Google Scholar was used to check whether relevant articles were included in the guidelines. The characteristics of these articles were analyzed and future research hotspots were predicted. RESULTS 389 relevant articles were included in the analysis. The number of articles increased rapidly from 1972 to 2022, from 5 (1.3%; 1972-1982) to 208 (53.5%; 2013-2022) articles. 338 (86.9%) articles were included in relevant guidelines. According to corresponding author location, Europe was the source of the highest number of publications (183; 47.0%), followed by the Americas (152; 39.1%) and the Western Pacific (54; 13.9%). The number of publications steadily increased over time in the USA, England, Canada, Australia, Germany, and France, and surged in China and Spain, especially in the last 5 years. In recent years, endovascular therapy has accounted for the majority of ischemic stroke-related RCT articles. CONCLUSIONS Numerous RCTs related to ischemic stroke have been conducted in recent decades, and both the number of articles and their contribution to guideline updates are increasing. Also, a shift in research topics was observed. However, great regional imbalances in this research exist, calling for more research to be conducted in specific regions to promote the generalizability of trial conclusions.
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Affiliation(s)
- Tianhua Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Chengyu Song
- Department of Science and Technology, Medical Library, Peking University Huilongguan Clinical Medical School, Beijing Huilongguan Hospital, Beijing, China
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ran Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Hengxiao Zhao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Wenbo Cao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Haozhi Gong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Chao Zhang
- Escope Innovation Academy, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute (China-INI), Beijing, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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Li M, Yang Q, Shi J, Zhang X, Lin H, Ge F. Ticagrelor plus aspirin in patients with minor ischemic stroke and transient ischemic attack: a network meta-analysis. BMC Neurol 2023; 23:303. [PMID: 37580668 PMCID: PMC10424353 DOI: 10.1186/s12883-023-03356-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was recommended as the secondary prevention of minor ischemic stroke or transient ischaemic attack (TIA). However, genetic polymorphisms of CYP2C19 had been identified as the major cause of poor responsiveness to clopidogrel. Ticagrelor, unlike clopidogrel, did not depend on metabolic activation, but it remained unclear whether ticagrelor was superior to clopidogrel in ischemic stroke. We performed a network meta-analysis to compare the efficacy and safety of ticagrelor, clopidogrel, and aspirin in the minor ischemic stroke and TIA populations. METHODS Databases of Cochrane Library, ClinicalTrials.gov, and PubMed were searched up to June 19, 2023. Randomized controlled trials (RCTs) assessing antiplatelet drugs for minor stroke or TIA were included. Statistical processing was conducted by using multivariate meta-analysis routines of STATA. RESULTS Seven RCTs were included involving 41,745 participants. There was no significant difference between the two DAPTs in preventing stroke recurrence (OR, 1.16; 95% CI, 0.93-1.44), ischemic stroke recurrence (OR, 1.16; 95% CI, 0.93-1.45), and major hemorrhage (OR, 1.22; 95% CI, 0.62,2.39). Compared with aspirin alone, the two DAPT regimen reduced the risk of stroke recurrence (clopidogrel: OR, 0.69; 95% CI, 0.60-0.80, ticagrelor: OR, 0.66; 95% CI, 0.49-0.87) and ischemic stroke recurrence, but increased the incidence of major hemorrhage (clopidogrel: OR, 2.05; 95% CI, 1.22- 3.77; ticagrelor: OR, 2.55; 95% CI, 1.25-4.99). Despite being associated with a higher risk of any bleeding, ticagrelor did not impact the composite of vascular events or mortality. While ticagrelor and aspirin reduced the risk of ischemic stroke recurrence (OR, 0.77; 95% CI, 0.63- 0.92) without increasing the risk of major bleeding (OR 0.94; 95% CI 0.45-1.95) in the Asian population mainly Chinese. CONCLUSIONS DAPT was superior to aspirin in stroke prevention, but little difference existed between the two DAPT regimens. Asian population mainly Chinese may benefit from DAPT with aspirin and ticagrelor. But further head-to-head RCTs are needed to validate the study results.
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Affiliation(s)
- Mingxia Li
- Department of Neurology, Xi'an International Medical Center Hospital, Xitai Road, Gaoxin District, Xi'an City, 710010, Shaanxi Province, China
| | - Qianru Yang
- Department of Neurology, Xi'an International Medical Center Hospital, Xitai Road, Gaoxin District, Xi'an City, 710010, Shaanxi Province, China
| | - Jiankuan Shi
- Department of Neurology, Xi'an International Medical Center Hospital, Xitai Road, Gaoxin District, Xi'an City, 710010, Shaanxi Province, China
| | - Xiaolong Zhang
- Department of Neurology, Xi'an International Medical Center Hospital, Xitai Road, Gaoxin District, Xi'an City, 710010, Shaanxi Province, China
| | - Hong Lin
- Department of Neurology, Xi'an International Medical Center Hospital, Xitai Road, Gaoxin District, Xi'an City, 710010, Shaanxi Province, China.
| | - Fangfang Ge
- Department of Neurology, Xi'an International Medical Center Hospital, Xitai Road, Gaoxin District, Xi'an City, 710010, Shaanxi Province, China.
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Sun L, Wang S, Song Y, Zhao W, Zheng M, Yin H, Zhang J, Meng Y, Wang W, Han J. Ticagrelor versus clopidogrel after intracranial stent angioplasty: a real-world study. Front Neurol 2023; 14:1232958. [PMID: 37638175 PMCID: PMC10455925 DOI: 10.3389/fneur.2023.1232958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Objective It was unknown whether a regimen of aspirin plus ticagrelor (aspirin-ticagrelor) attenuates ischemic vascular events without increasing bleeding risk in patients who had undergone intracranial stenting compared with an aspirin plus clopidogrel (aspirin-clopidogrel) regimen. This article compares the efficacy and safety outcomes of the two double antibody regimens in patients undergoing intracranial stent and investigates whether aspirin-ticagrelor could be an alternative antiplatelet agent without increasing the risk of bleeding. Methods We conducted a retrospective analysis of our database for patients who had undergone intracranial stenting. From January 2017 to May 2021, consecutive patients treated with endovascular stenting were identified and dichotomized by whether aspirin-ticagrelor or aspirin-clopidogrel were used. The outcomes were compared by propensity score matching. Results A total of 340 patients treated with intracranial stent were included. Of all, 132 patients were matched. At 180 days, ischemic vascular events occurred in one patient (1.5%) in the aspirin-ticagrelor group and in six patients (9.1%) in the aspirin-clopidogrel group. Although the absolute incidence of ischemic vascular events [1.5% (1/66) vs. 9.1% (6/66), p = 0.125] was lower in the aspirin-ticagrelor group than in the aspirin-clopidogrel group, there were no statistical differences. There were no statistical differences in ischemic vascular events, ischemic stroke, or death up to 180 days between the two groups. In addition, the incidence of bleeding did not differ. No intracranial hemorrhage or mild bleeding occurred. No statistically significant difference was noted in restenosis and symptomatic restenosis at follow-up. Conclusion In our study involving patients with acute ischemic stroke who had undergone intracranial stenting, aspirin-ticagrelor was not found to be superior to aspirin-clopidogrel in reducing the rate of ischemic vascular events. The risk of bleeding did not differ between the two groups. Aspirin-ticagrelor does not lower total restenosis and symptomatic restenosis risk at follow-up.
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Affiliation(s)
- Lili Sun
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Neurology, Shandong Institute of Neuroimmunology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Shuzhen Wang
- Shandong Engineering and Technology Research Center for Pediatric Drug Development, Department of Pediatrics, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yun Song
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Neurology, Shandong Institute of Neuroimmunology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Wei Zhao
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Neurology, Shandong Institute of Neuroimmunology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Meimei Zheng
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Neurology, Shandong Institute of Neuroimmunology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Hao Yin
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Neurology, Shandong Institute of Neuroimmunology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Jun Zhang
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Neurology, Shandong Institute of Neuroimmunology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Yao Meng
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Neurology, Shandong Institute of Neuroimmunology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Wei Wang
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Neurology, Shandong Institute of Neuroimmunology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Ju Han
- Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Department of Neurology, Shandong Institute of Neuroimmunology, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Jinan, China
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Zhang J, Wang A, Tian X, Meng X, Xie X, Jing J, Lin J, Wang Y, Li Z, Liu L, Li H, Jiang Y, Zhao X, Wang Y. Impact of body mass index on efficacy and safety of ticagrelor versus clopidogrel in patients with minor stroke or transient ischemic attack. CMAJ 2023; 195:E897-E904. [PMID: 37429630 PMCID: PMC10446134 DOI: 10.1503/cmaj.230262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Body mass index (BMI) may affect the response to platelet P2Y12 receptor inhibitors. We aimed to explore whether BMI influenced the efficacy and safety of ticagrelor and clopidogrel for secondary prevention of minor ischemic stroke or transient ischemic attack (TIA) among patients enrolled in the CHANCE-2 (Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II) trial. METHODS In a multicentre, randomized, double-blind, placebo-controlled trial, conducted in China, we randomized patients with minor stroke or TIA who carried the CYP2C19 loss-of-function allele to receive either ticagrelor-acetylsalicylic acid (ASA) or clopidogrel-ASA. We classified patients into obese (BMI ≥ 28) or nonobese (BMI < 28) groups. The primary efficacy outcome was stroke within 90 days, and the primary safety outcome was severe or moderate bleeding within 90 days. RESULTS Among 6412 patients, 876 were classified as obese and 5536 were classified as nonobese. Compared with clopidogrel-ASA, ticagrelor-ASA was associated with a significantly lower rate of stroke within 90 days among patients with obesity (25 [5.4%] v. 47 [11.3%]; hazard ratio [HR] 0.51, 95% confidence interval [CI] 0.30-0.87), but not among those in the nonobese group (166 [6.0%] v. 196 [7.0%]; HR 0.84, 95% CI 0.69-1.04) The interaction of treatment and BMI group was significant (p for interaction = 0.04). We did not observe any difference by BMI group in rates of severe or moderate bleeding (9 [0.3%] v. 10 [0.4%] in the nonobese group; 0 [0.0%] v. 1 [0.2%] in the obese group; p for interaction = 0.99). INTERPRETATION In this secondary analysis of a randomized controlled trial involving patients with minor ischemic stroke or TIA, compared with clopidogrel-ASA, patients with obesity received more clinical benefit from ticagrelor-ASA therapy than those without obesity. TRIAL REGISTRATION Clinicaltrials.gov, no. NCT04078737.
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Affiliation(s)
- Jia Zhang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xue Tian
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuewei Xie
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxi Lin
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao Li
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Department of Neurology (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang) and The China National Clinical Research Center for Neurological Diseases (Zhang, A. Wang, Tian, Meng, Xie, Jing, Lin, Yilong Wang, Z. Li, Liu, H. Li, Jiang, Zhao, Yongjun Wang), Beijing Tiantan Hospital and Department of Epidemiology and Health Statistics (Tian), School of Public Health, Capital Medical University; Beijing Municipal Key Laboratory of Clinical Epidemiology (Tian); Research Unit of Artificial Intelligence in Cerebrovascular Disease (Zhao), Chinese Academy of Medical Sciences; Beijing Institute of Brain Disorders (Zhao), Collaborative Innovation Center for Brain Disorders; Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Kong D, Tan R, Gao Y, Gao S, Feng Z, Qi H, Shen B, Yang L, Shen X, Jing X, Zhao X. Arterial Baroreflex Dysfunction Promotes Neuroinflammation by Activating the Platelet CD40L/Nuclear Factor Kappa B Signaling Pathway in Microglia and Astrocytes. Neurochem Res 2023; 48:1691-1706. [PMID: 36592325 PMCID: PMC10119255 DOI: 10.1007/s11064-022-03852-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/06/2022] [Accepted: 12/20/2022] [Indexed: 01/03/2023]
Abstract
Arterial baroreflex (ABR) dysfunction has previously been associated with neuroinflammation, the most common pathological feature of neurological disorders. However, the mechanisms mediating ABR dysfunction-induced neuroinflammation are not fully understood. In the present study, we investigated the role of platelet CD40 ligand (CD40L) in neuroinflammation in an in vivo model of ABR dysfunction, and microglia and astrocyte activation in vitro. ABR dysfunction was induced in Sprague‒Dawley rats by sinoaortic denervation (SAD). We used ELSA and immunofluorescence to assess the effect of platelet CD40L on glial cell polarization and the secretion of inflammatory factors. By flow cytometry, we found that rats subjected to SAD showed a high level of platelet microaggregation and upregulation of CD40L on the platelet surface. The promotion of platelet invasion and accumulation was also observed in the brain tissues of rats subjected to SAD. In the animal model and cultured N9 microglia/C6 astrocytoma cells, platelet CD40L overexpression promoted neuroinflammation and activated M1 microglia, A1 astrocytes, and the nuclear factor kappa B (NFκB) signaling pathway. These effects were partially blocked by inhibiting platelet activity with clopidogrel or inhibiting CD40L-mediated signaling. Our results suggest that during ABR dysfunction, CD40L signaling in platelets converts microglia to the M1 phenotype and astrocytes to the A1 phenotype, activating NFκB and resulting in neuroinflammation. Thus, our study provides a novel understanding of the pathogenesis of ABR dysfunction-induced neuroinflammation and indicates that targeting platelet CD40L is beneficial for treating central nervous system (CNS) disorders associated with ABR dysfunction.
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Affiliation(s)
- Deping Kong
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China
| | - Rui Tan
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China
| | - Yongfeng Gao
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China
| | - Shan Gao
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China
| | - Zhaoyang Feng
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China
| | - Huibin Qi
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China
| | - Bowen Shen
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China
| | - Lili Yang
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China
| | - Xuri Shen
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China
| | - Xiuli Jing
- School of Chemistry and Pharmaceutical Engineering, Shandong First Medical University & Shandong Academy of Medical Science, 271016, Tai'an, China
| | - Xiaomin Zhao
- Institute of Pharmacology, Shandong First Medical University & Shandong Academy of Medical Sciences, No. 619 Changcheng Road, 271016, Tai'an, People's Republic of China.
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Wright S, McDermott J, Sen D, Smith C, Newman W, Payne K. Development of a point-of-care genetic test for effective treatment of ischaemic stroke: an early model-based cost-effectiveness analysis. Wellcome Open Res 2023; 8:183. [PMID: 37869733 PMCID: PMC10587658 DOI: 10.12688/wellcomeopenres.19202.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 10/24/2023] Open
Abstract
Background: People who have experienced a stroke are at high risk of recurrent strokes. Clopidogrel is prescribed to people who have had a non-cardioembolic stroke. There is evidence that clopidogrel is not effective for patients with CYP2C19 loss-of-function alleles. Pharmacogenetic testing is a potential strategy to identify such patients and guide prescription of appropriate antiplatelet treatment. This study aimed to provide an early estimate of the cost-effectiveness of using a point-of-care pharmacogenetic CYP2C19 test in the UK National Health System. Methods: A decision-analytic model comprising a linked decision tree and Markov model were created in R comparing pharmacogenetic testing with current prescribing practice. In the pharmacogenetic testing arm, patients identified to have one of three loss-of-function alleles were prescribed modified-release dipyridamole and aspirin or aspirin alone. Indicative data were sourced from reviews of the literature supported by expert consultation to select the most appropriate value for the input parameters. The healthcare costs (£;2021) and quality adjusted life years resulting from each strategy were estimated and the incremental cost-effectiveness of testing calculated. Deterministic threshold analysis and probabilistic sensitivity analysis (PSA) was conducted to account for uncertainty in the parameter estimates. Results: The pharmacogenetic testing strategy generated 0.107 additional QALYs per patient tested and saved £512. Pharmacogenetic testing dominated current prescribing practice. The results were robust to extreme changes in key input variables. The PSA suggested that there was a 77% chance that pharmacogenetic testing would be cost-effective with a 62% chance it is cost-saving. Conclusions: A point-of-care pharmacogenetic test to guide prescription of clopidogrel for people who have experienced a stroke has the potential to provide a significant health gain by preventing secondary strokes and may save resources in the health system. This early economic analysis has also informed the direction for future research.
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Affiliation(s)
- Stuart Wright
- Manchester Centre for Health Economics, The University of Manchester, Manchester, M139PL, UK
| | - John McDermott
- Manchester Centre for Genomic Medicine, The University of Manchester, Manchester, M13 9PL, UK
- Division of Evolution, Infection and Genomics, The University of Manchester, Manchester, M13 9PL, UK
| | - Dwaipayan Sen
- Greater Manchester Comprehensive Stroke Centre, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Salford, M6 8HD, UK
| | - Craig Smith
- Greater Manchester Comprehensive Stroke Centre, Geoffrey Jefferson Brain Research Centre, Salford Royal Foundation Trust, Salford, M6 8HD, UK
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, England, M13 9PL, UK
| | - William Newman
- Manchester Centre for Genomic Medicine, The University of Manchester, Manchester, M13 9PL, UK
- Division of Evolution, Infection and Genomics, The University of Manchester, Manchester, M13 9PL, UK
| | - Katherine Payne
- Manchester Centre for Health Economics, The University of Manchester, Manchester, M139PL, UK
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Liu H, Jing J, Wang A, Xu Q, Meng X, Li H, Li Z, Wang Y. Genotype-Guided Dual Antiplatelet Therapy in Minor Stroke or Transient Ischemic Attack With a Single Small Subcortical Infarction. Neurology 2023; 100:e1643-e1654. [PMID: 36697242 PMCID: PMC10115499 DOI: 10.1212/wnl.0000000000206775] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/17/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Single small subcortical infarction (SSSI) is an important stroke subtype. The optimal antiplatelet medication for patients with ischemic stroke with an SSSI is still unclear. We aimed to test the efficacy and safety of ticagrelor-aspirin in preventing stroke recurrence among patients with SSSI in the Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial. METHODS In the CHANCE-2 trial, patients with a minor stroke or TIA who carried CYP2C19 loss-of-function (LOF) alleles were randomly assigned within 24 hours after symptom onset, to either ticagrelor-aspirin (placebo clopidogrel plus a 180 mg loading dose of ticagrelor on day 1, followed by 90 mg twice daily on days 2-90) or clopidogrel-aspirin (placebo ticagrelor plus a 300 mg loading dose of clopidogrel on day 1, followed by 75 mg daily on days 2-90). Aspirin was applied during the first 21 days. Patients who had an SSSI (diffusion-weighted imaging lesion diameter ≤20 mm) were included in this analysis and further categorized into 2 types according to whether they had the responsible intracranial artery stenosis (ICAS): SSSI + ICAS and SSSI - ICAS. The primary efficacy outcome was a new stroke at 90 days. RESULTS Among 2,143 eligible patients, 340 had the responsible ICAS, and 1,803 did not. Ticagrelor-aspirin reduced stroke recurrence among all patients with SSSI (hazard ratio [HR]: 0.55; 95% CI 0.38-0.78; p = 0.001) compared with clopidogrel-aspirin. Stroke recurrence occurred in 35/901 (3.9%) patients with SSSI - ICAS on ticagrelor-aspirin and in 72/902 (8.0%) on clopidogrel-aspirin (hazard ratio [HR]: 0.45; 95% CI 0.29-0.68; p < 0.001). In patients with SSSI + ICAS, the corresponding event rates were 14/176 (8.0%) and 13/164 (7.9%), respectively (HR: 1.20; 95% CI 0.45-3.23; p = 0.71; p for interaction = 0.08). The risk of severe or moderate bleeding only occurred in patients with SSSI - ICAS (5/901 [0.6%] vs 5/902 [0.6%]). DISCUSSION In this prespecified substudy, ticagrelor-aspirin was superior to clopidogrel-aspirin in reducing the risk of stroke at 90 days among patients with SSSI who carried CYP2C19 LOF allele(s). Although there was no treatment-by-heterogeneous etiology interaction, a greater absolute risk reduction of stroke was observed in patients with SSSI - ICAS than in those with SSSI + ICAS. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that ticagrelor and aspirin reduced the risk of stroke recurrence compared with clopidogrel with aspirin in adult patients with acute minor SSSI.
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Affiliation(s)
- Huihui Liu
- From the Department of Neurology (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing; and Department of Neurology and Suzhou Clinical Research Center of Neurological Disease (H. Liu), the Second Affiliated Hospital of Soochow University, China
| | - Jing Jing
- From the Department of Neurology (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing; and Department of Neurology and Suzhou Clinical Research Center of Neurological Disease (H. Liu), the Second Affiliated Hospital of Soochow University, China
| | - Anxin Wang
- From the Department of Neurology (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing; and Department of Neurology and Suzhou Clinical Research Center of Neurological Disease (H. Liu), the Second Affiliated Hospital of Soochow University, China.
| | - Qin Xu
- From the Department of Neurology (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing; and Department of Neurology and Suzhou Clinical Research Center of Neurological Disease (H. Liu), the Second Affiliated Hospital of Soochow University, China
| | - Xia Meng
- From the Department of Neurology (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing; and Department of Neurology and Suzhou Clinical Research Center of Neurological Disease (H. Liu), the Second Affiliated Hospital of Soochow University, China
| | - Hao Li
- From the Department of Neurology (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing; and Department of Neurology and Suzhou Clinical Research Center of Neurological Disease (H. Liu), the Second Affiliated Hospital of Soochow University, China
| | - Zixiao Li
- From the Department of Neurology (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing; and Department of Neurology and Suzhou Clinical Research Center of Neurological Disease (H. Liu), the Second Affiliated Hospital of Soochow University, China
| | - Yongjun Wang
- From the Department of Neurology (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing Tiantan Hospital, Capital Medical University; China National Clinical Research Center for Neurological Diseases (H. Liu, J.J., A.W., Q.X., X.M., H. Li, Z.L., Y.W.), Beijing; and Department of Neurology and Suzhou Clinical Research Center of Neurological Disease (H. Liu), the Second Affiliated Hospital of Soochow University, China.
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Ma X, Li D, Liu S, Chen Y, Zhong P. Efficacy and Safety of Ticagrelor versus Aspirin and Clopidogrel for Stroke Prevention in Patients with Vascular Disease: A Systematic Review and Meta-Analysis. Eur Neurol 2023; 86:229-241. [PMID: 37068471 DOI: 10.1159/000530504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 03/25/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Currently, it is still controversial to treat stroke with ticagrelor alone. The purpose of our study was to systematically review and analyze the efficacy and safety of ticagrelor on cerebrovascular outcomes in patients with vascular risk factors. METHODS The PubMed, Cochrane Library, and Embase databases were systematically searched using the keywords stroke, ticagrelor, clopidogrel, and aspirin to identify randomized controlled trials (RCTs). Primary outcomes included reported stroke, ischemic stroke, and complex events; the secondary outcome was hemorrhagic stroke. The safety outcomes included major bleeding events, major or minor bleeding, and intracranial bleeding. The pooled odds ratio (OR), hazard ratios (HRs), and 95% confidence interval (CI) were calculated. We used I2 statistics to assess statistical heterogeneity. RESULTS This meta-analysis included 15 RCTs involving 63,865 patients. Compared to the control group, ticagrelor reduced the risk of stroke (OR: 0.90; 95% CI: 0.81-0.99, p = 0.03; I2 = 3%), ischemic stroke (OR: 0.81; 95% CI: 0.74-0.90, p < 0.0001; I2 = 0%). Ticagrelor was not associated with an increased risk of all-cause mortality (OR: 0.94; 95% CI: 0.84-1.06, p = 0.31; I2 = 62%), major bleeding (OR: 1.06; 95% CI: 0.97-1.15, p = 0.20; I2 = 17%), hemorrhagic strokes (OR: 1.22, 95% CI: 0.76-1.96, p = 0.41; I2 = 0%), and intracranial hemorrhage (OR: 1.06; 95% CI: 0.78-1.43, p = 0.71; I2 = 12%). There was an increased risk of major or minor bleeding with ticagrelor compared to the control group (OR: 1.40; 95% CI: 1.19-1.66, p < 0.0001; I2 = 56%). Additional analyses demonstrated that ticagrelor reduced the risk of incident recurrent stroke (HR: 0.83; 95% CI: 0.75-0.93, p = 0.0009; I2 = 0%), recurrent ischemic stroke (HR: 0.79; 95% CI: 0.71-0.89, p < 0.0001; I2 = 0%) among patients with a history of acute ischemic stroke (AIS) or transient ischemic attack (TIA). There were no significant differences in safety outcomes. CONCLUSION Ticagrelor is slightly better than clopidogrel and aspirin in preventing stroke, especially ischemic stroke, with significant safety risks. For patients with a history of AIS/TIA, the use of ticagrelor was superior to the use of clopidogrel or aspirin in reducing the risk of subsequent stroke. We believe that ticagrelor is a potential alternative to aspirin or clopidogrel in some cases, especially for patients with CYP2C19 deficiency.
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Affiliation(s)
- Xibo Ma
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China,
| | - Danfeng Li
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China
| | - Shihua Liu
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China
| | - Yan Chen
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China
| | - Ping Zhong
- Suzhou Hospital of Anhui Medical University, Yongqiao District, Suzhou, China
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Bhatia K, Ladd LM, Carr KH, Di Napoli M, Saver JL, McCullough LD, Hosseini Farahabadi M, Alsbrook DL, Hinduja A, Ortiz Garcia JG, Sabbagh SY, Jafarli A, Divani AA. Contemporary Antiplatelet and Anticoagulant Therapies for Secondary Stroke Prevention: A Narrative Review of Current Literature and Guidelines. Curr Neurol Neurosci Rep 2023; 23:235-262. [PMID: 37037980 DOI: 10.1007/s11910-023-01266-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Stroke is a leading cause of death and disability worldwide. The annual incidence of new or recurrent stroke is approximately 795,000 cases per year in the United States, of which 87% are ischemic in nature. In addition to the management of modifiable high-risk factors to reduce the risk of recurrent stroke, antithrombotic agents (antiplatelets and anticoagulants) play an important role in secondary stroke prevention. This review will discuss the published literature on the use of antiplatelets and anticoagulants in secondary prevention of acute ischemic stroke and transient ischemic attack (TIA), including their pharmacology, efficacy, and adverse effects. We will also highlight the role of dual antiplatelet therapy (DAPT) in secondary stroke prevention, along with supporting literature. RECENT FINDINGS Single antiplatelet therapy (SAPT) with aspirin or clopidogrel reduces the risk of recurrent ischemic stroke in patients with non-cardioembolic ischemic stroke or TIA. However, as shown in recent trials, short-term DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute non-cardioembolic stroke or high-risk TIA. Although short-term DAPT is highly effective in preventing recurrent stroke, a more prolonged course can increase bleeding risks without additional benefit. DAPT for 90 days, followed by aspirin monotherapy for patients with large vessel intracranial atherosclerotic disease, is suitable for secondary stroke prevention. However, patients need to be monitored for both minor (e.g., bruising) and major (e.g., intracranial) bleeding complications. Conversely, oral warfarin and newer direct oral anticoagulant (DOACs) such as dabigatran, rivaroxaban, apixaban, and edoxaban are the agents of choice for secondary stroke prevention in patients with non-valvular cardioembolic strokes. DOACs may be preferred over warfarin due to decreased bleeding risks, including ICH, lack of need for international normalized ratio monitoring, no dietary restrictions, and limited drug-drug interactions. The choice between different antiplatelets and anticoagulants for prevention of ischemic stroke depends on the underlying stroke mechanism, cytochrome P450 2C19 polymorphisms, bleeding risk profile, compliance, drug tolerance, and drug resistance. Physicians must carefully weigh each patient's relative benefits and bleeding risks before initiating an antiplatelet/anticoagulant treatment regimen. Further studies are warranted to study the optimal duration of DAPT in symptomatic intracranial atherosclerosis since the benefit is most pronounced in the short term while the bleeding risk remains high during the extended duration of therapy.
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Affiliation(s)
- Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Lindsey M Ladd
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kelsey H Carr
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, L'Aquila, Italy
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Louise D McCullough
- Department of Neurology, McGovern Medical School, University of Texas Health Sciences Center, Houston, TX, USA
| | | | - Diana L Alsbrook
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jorge G Ortiz Garcia
- Department of Neurology, the University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Sara Y Sabbagh
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Alibay Jafarli
- Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
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30
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Micieli A, Singh N, Jahn B, Siebert U, Menon BK, Demchuk AM. Cost-effectiveness of testing for CYP2C19 loss-of-function carriers following transient ischemic attack/minor stroke: A Canadian perspective. Int J Stroke 2023; 18:416-425. [PMID: 35739635 DOI: 10.1177/17474930221111898] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The CHANCE-2 study compared 3 weeks of aspirin-ticagrelor to aspirin-clopidogrel in CYP2C19 loss-of-function (LOF) allele carriers following a transient ischemic attack (TIA)/minor stroke and demonstrated a modestly lower risk of stroke recurrence with aspirin-ticagrelor. This stroke protection was largely for minor stroke and came at an increased risk of bleeding. The cost-effectiveness of implementing testing for LOF allele status to personalize antiplatelet regimen for secondary stroke prevention after a TIA/minor stroke in the Canadian health care context is unknown. METHODS Cost-effectiveness analysis using a decision-analytic Markov cohort model with a lifetime horizon was performed to determine the costs and health benefits of testing for LOF allele status compared with no testing (current standard of care). The population of interest was patients living in Canada who suffered a TIA/minor stroke. Outcomes of interest were life-years gained (LYG), quality-adjusted life years (QALY) gained, costs (reported in 2022 Canadian dollars), and the incremental cost-effectiveness ratio (ICER). We adopted the perspective of the Federal, Provincial, and Territorial Ministries of Health and used a 1.5% annual discount rate. Sensitivity analyses were performed to assess uncertainty. RESULTS Compared to standard of care, LOF allele testing leads to 0.14 LYG (undiscounted), 0.12 QALYs gained (undiscounted), and additional lifetime costs of CAD$432 (discounted) per patient. The ICER of the LOF allele testing strategy is CAD$4310 per QALY gained compared with standard of care. The probabilistic sensitivity analyses demonstrated that LOF allele testing was cost-effective in more than 99.99% of simulations using a willingness-to-pay threshold of CAD$50,000 per QALY. CONCLUSION Based on available evidence, testing for LOF allele followed by short duration 3 weeks of aspirin-ticagrelor compared to standard-of-care aspirin-clopidogrel can lead to prolonged life and improved quality of life and can be considered very cost-effective when compared with other well-accepted technologies in health and medicine.
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Affiliation(s)
- Andrew Micieli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Beate Jahn
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT -University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Uwe Siebert
- Institute of Public Health, Medical Decision Making and Health Technology Assessment, Department of Public Health, Health Services Research and Health Technology Assessment, UMIT -University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Center for Health Decision Science, Departments of Epidemiology and Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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31
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Mazzaccaro D, Giannetta M, Ranucci M, Righini P, Di Dedda U, Baryshnikova E, Milani V, Nano G. Clopidogrel Resistance and Ticagrelor Replacement in Dual Antiplatelet Therapy for Carotid Artery Stenting. Ann Vasc Surg 2023; 90:128-136. [PMID: 36270550 DOI: 10.1016/j.avsg.2022.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/25/2022] [Accepted: 09/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUNDS Resistance to the pharmacological effect of clopidogrel in patients undergoing dual antiplatelet therapy for carotid stenting may increase the risk of periprocedural neurological events. The purpose of the study was to describe the phenomenon of clopidogrel resistance in a series of patients undergoing carotid stenting. METHODS Data of patients who consecutively underwent carotid stenting from November 2016 to December 2020 for a significant stenosis and who underwent a dual antiplatelet therapy using acetyl-salicylic acid and clopidogrel were prospectively collected. Patients who were already taking a different thienopyridine were excluded. The effectiveness of antiplatelet drugs was assessed by the impedance aggregometry test. Primary endpoint was to evaluate the incidence of clopidogrel resistance and the effectiveness of ticagrelor as alternative therapy. P values < 0.05 were considered statistically significant. RESULTS Two-hundred patients (80 females, 40%) underwent stenting for carotid stenosis (94% asymptomatic). The phenomenon of clopidogrel resistance was observed in 38 patients (19%), in whom clopidogrel was replaced by ticagrelor (90 mg/bis in die) with 100% effectiveness at aggregometry test. Platelet counts was associated to clopidogrel resistance (P = 0.001). There was no stent thrombosis at 30 days, neither major hemorrhagic events; a total of 12/200 major adverse cardiovascular events occurred (6%), including 1 in the group of patients who took ticagrelor and 11 in group of patients under clopidogrel (2.6% versus 6.7%, P = 0.55). CONCLUSIONS Clopidogrel was ineffective in 19% of patients undergoing carotid stenting. Platelet count seemed to affect this phenomenon. In these patients, clopidogrel was effectively replaced by ticagrelor.
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Affiliation(s)
- Daniela Mazzaccaro
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
| | - Matteo Giannetta
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Paolo Righini
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Umberto Di Dedda
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Ekaterina Baryshnikova
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Valentina Milani
- Scientific Directorate, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Giovanni Nano
- Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy; Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
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32
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Ticagrelor Resistance in Cardiovascular Disease and Ischemic Stroke. J Clin Med 2023; 12:jcm12031149. [PMID: 36769796 PMCID: PMC9918175 DOI: 10.3390/jcm12031149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/19/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023] Open
Abstract
Ticagrelor, acting as a reversible platelet aggregation inhibitor of P2Y12 receptors (P2Y12R), is regarded as one of the first-line antiplatelet drugs for acute cardiovascular diseases. Though the probability of ticagrelor resistance is much lower than that of clopidogrel, there have been recent reports of ticagrelor resistance. In this review, we summarized the clinical application of ticagrelor and then presented the criteria and current status of ticagrelor resistance. We further discussed the potential mechanisms for ticagrelor resistance in terms of drug absorption, metabolism, and receptor action. In conclusion, the incidences of ticagrelor resistance fluctuated between 0 and 20%, and possible mechanisms mainly arose from its absorption and receptor action. Specifically, a variety of factors, such as the drug form of ticagrelor, gut microecology, and the expression and function of P-glycoprotein (P-gp) and P2Y12R, have been shown to be associated with ticagrelor resistance. The exact mechanisms of ticagrelor resistance warrant further exploration, which may contribute to the diagnosis and treatment of ticagrelor resistance.
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Abstract
Antiplatelet therapy is used in the treatment of patients with acute coronary syndromes, stroke, and those undergoing percutaneous coronary intervention. Clopidogrel is the most widely used antiplatelet P2Y12 inhibitor in clinical practice. Genetic variation in CYP2C19 may influence its enzymatic activity, resulting in individuals who are carriers of loss-of-function CYP2C19 alleles and thus have reduced active clopidogrel metabolites, high on-treatment platelet reactivity, and increased ischemic risk. Prospective studies have examined the utility of CYP2C19 genetic testing to guide antiplatelet therapy, and more recently published meta-analyses suggest that pharmacogenetics represents a key treatment strategy to individualize antiplatelet therapy. Rapid genetic tests, including bedside genotyping platforms that are validated and have high reproducibility, are available to guide selection of P2Y12 inhibitors in clinical practice. The aim of this review is to provide an overview of the background and rationale for the role of a guided antiplatelet approach to enhance patient care.
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Affiliation(s)
- Matteo Castrichini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA;
| | - Jasmine A Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Naveen Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA;
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34
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Zhang X, Jiang S, Xue J, Ding Y, Gu J, Hu L, Xu X, Li Z, Kong Y, Li Y, Zhu X, Yue Y. Personalized antiplatelet therapy guided by clopidogrel pharmacogenomics in acute ischemic stroke and transient ischemic attack: A prospective, randomized controlled trial. Front Pharmacol 2023; 13:931405. [PMID: 36744212 PMCID: PMC9889636 DOI: 10.3389/fphar.2022.931405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 11/16/2022] [Indexed: 01/20/2023] Open
Abstract
Background: Clopidogrel is frequently used in patients with ischemic stroke or transient ischemic attack (TIA), but its efficacy is hampered by inter-individual variability, due to genetic differences associated with clopidogrel metabolism. We conducted this randomized controlled trial to validate whether the personalized antiplatelet therapy based on clopidogrel pharmacogenomics and clinical characteristics leads to better clinical outcomes compared with standard treatment. Methods: Patients were randomly divided into the standard group or pharmacogenetic group, in which the pharmacogenetic group required the detection of the genotyping of CYP2C19*2, CYP2C19*3, and CYP2C19*17. Patients were followed up for 90 days for the primary efficacy endpoint of new stroke events, secondary efficacy endpoint of individual or composite outcomes of the new clinical vascular events, and the incidence of disability. The primary safety outcome was major bleeding. Results: A total of 650 patients underwent randomization, among which 325 were in the pharmacogenomics group while 325 were in the standard group. Our study found after a 90-day follow-up, the risk of stroke and composite vascular events in the pharmacogenomics group was lower than that in the standard group. The incidence of disability significantly decreased in the pharmacogenomics group. In addition, no statistically significant differences were observed in bleeding events between the two groups. Conclusion: The present study demonstrates that personalized antiplatelet therapy guided by clopidogrel pharmacogenomics and clinical characteristics can significantly improve the net clinical benefit of ischemic stroke or TIA patients during the 90-day treatment period without increasing bleeding risk.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Youmei Li
- *Correspondence: Youmei Li, ; Xiaoqiong Zhu, ; Yunhua Yue,
| | - Xiaoqiong Zhu
- *Correspondence: Youmei Li, ; Xiaoqiong Zhu, ; Yunhua Yue,
| | - Yunhua Yue
- *Correspondence: Youmei Li, ; Xiaoqiong Zhu, ; Yunhua Yue,
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35
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Fukuma K, Yamagami H, Ihara M, Tanaka T, Miyata T, Miyata S, Kokame K, Nishimura K, Nakaoku Y, Yamamoto H, Hayakawa M, Kamiyama K, Enomoto Y, Itabashi R, Furui E, Manabe Y, Ezura M, Todo K, Hashikawa K, Uchiyama S, Toyoda K, Nagatsuka K. P2Y12 Reaction Units and Clinical Outcomes in Acute Large Artery Atherosclerotic Stroke: A Multicenter Prospective Study. J Atheroscler Thromb 2023; 30:39-55. [PMID: 35249906 PMCID: PMC9899699 DOI: 10.5551/jat.63369] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
AIMS We aimed to determine the association between acute platelet reactivity and clinical outcome in acute ischemic stroke (AIS) or transient ischemic attack (TIA) with large-artery atherosclerosis (LAA). METHODS In this prospective, 16-multicenter study, we enrolled AIS/TIA patients with LAA receiving clopidogrel. We assessed the association of P2Y12 reaction units (PRU) 24 hours after initiation of antiplatelets with the CYP2C19 genotype and recurrent ischemic stroke within 90 days, and the difference between acute (≤ 7 days) and subacute (8-90 days) phases. RESULTS Among the 230 AIS/TIA patients enrolled, 225 with complete outcome data and 194 with genetic results were analyzed. A higher PRU was significantly associated with recurrent ischemic stroke within 90 days (frequency, 16%), and within 7 days (10%). Twenty-nine patients (15%) belonged to a CYP2C19 poor metabolizer group (CYP2C19*2/*2, *2/*3, or *3/*3). Multivariable receiver-operating characteristic analysis showed a greater area-under-the-curve (AUC) in predicting recurrence within 7 days, compared to 8-90 days (AUC, 0.79 versus 0.64; p=0.07), with a cut-off PRU of 254. Multivariable analysis showed high PRU (≥ 254), which had a comparable predictive performance for recurrent ischemic stroke within 7 days (odds ratio, 6.82; 95% CI, 2.23-20.9; p<0.001) to the CYP2C19 poor metabolizer genotype. The net reclassification improvement, calculated by adding high PRU (≥ 254) to a model including the CYP2C19 poor metabolizer genotype in the prediction of recurrence within 7 days, was 0.83 (p<0.001). CONCLUSIONS Acute PRU evaluation possesses predictive value for recurrent ischemic stroke, especially within 7 days in AIS/TIA with LAA.
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Affiliation(s)
- Kazuki Fukuma
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hiroshi Yamagami
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Osaka, Japan,Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tomotaka Tanaka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshiyuki Miyata
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan,Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Koichi Kokame
- Department of Molecular Pathogenesis, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kunihiro Nishimura
- Departments of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yuriko Nakaoku
- Departments of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Mikito Hayakawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yukiko Enomoto
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ryo Itabashi
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Eisuke Furui
- Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan
| | - Yasuhiro Manabe
- Department of Neurology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Kenichi Todo
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kazuo Hashikawa
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Shinichiro Uchiyama
- Clinical Research Center for Medicine, International University of Health and Welfare, Center for Brain and Cerebral Vessels,
Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazuyuki Nagatsuka
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
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36
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Jing J, Xie X, Johnston SC, Bath PM, Li Z, Zhao X, Liu L, Wang Y, Xu Q, Wang A, Jiang Y, Li H, Meng X, Wang Y. Genotype-Guided Dual Antiplatelet Use for Transient Ischemic Attack and Minor Stroke by Imaging Status: Subgroup Analysis of the CHANCE-2 Trial. Ann Neurol 2022; 93:783-792. [PMID: 36571569 DOI: 10.1002/ana.26589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study was performed to investigate whether ticagrelor/aspirin versus clopidogrel/aspirin can further reduce the residual risk of stroke recurrence in patients with positive diffusion-weighted imaging (DWI) in the High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial. METHODS Patients with DWI data in the CHANCE-2 trial were included and divided into those with and without acute infarction according to their DWI findings. The primary efficacy outcome and safety outcome were stroke recurrence and moderate to severe bleeding within 3 months of follow-up, respectively. RESULTS Of the 6,412 patients enrolled in the CHANCE-2 trial, 5,796 (90.4%) patients with DWI data were included in the subgroup analysis. A total of 4,369 patients (75.4%) had an acute infarction on DWI. Patients with positive DWI had higher risk of recurrent stroke (8.1%) than those without infarction (2.2%) within 3-month follow-up. Compared with clopidogrel/aspirin, ticagrelor/aspirin was associated with lower risk of stroke in patients with positive DWI (hazard ratio [HR] = 0.65, 95% confidence interval [CI] = 0.52-0.80, p < 0.001) than in those negative DWI (HR = 1.22, 95% CI = 0.55-2.72, p = 0.63), with a significant interaction association (p for interaction = 0.049). The risk of moderate to severe bleeding was similar between ticagrelor/aspirin and clopidogrel/aspirin treatment in the different groups. INTERPRETATION Our study demonstrates that imaging evaluation should be emphasized before targeting the best candidates for genotype-guided dual antiplatelet therapy in future clinical research and practice. ANN NEUROL 2023.
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Affiliation(s)
- Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Tiantan Neuroimaging Center of Excellence, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Philip M Bath
- Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qin Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Yu Q, Yang J, Wang J, Yu R, Li J, Cheng J, Hu Y, Li Z, Zheng N, Zhang Z, Li X, Wang Y, Du W, Zhu K, Chen X, Su J. DNA methylation profile in the whole blood of acute coronary syndrome patients with aspirin resistance. J Clin Lab Anal 2022; 37:e24821. [PMID: 36550638 PMCID: PMC9833987 DOI: 10.1002/jcla.24821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/07/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Aspirin resistance (AR) results in major adverse cardiovascular events, and DNA methylation might participate in the regulation of this pathological process. METHODS In present study, a sum of 35 patients with AR and 35 non-AR (NAR) controls were enrolled. Samples from 5 AR and 5 NAR were evaluated in an 850 BeadChip DNA methylation assay, and another 30 AR versus 30 NAR were evaluated to validate the differentially methylated CpG loci (DML). Then, qRT-PCR was used to investigate the target mRNA expression of genes at CpG loci. Finally, Gene Ontology (GO) as well as Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses were performed to reveal the enriched pathways. RESULTS The AR and NAR groups displayed significant differences in DNA methylation at 7707 positions, with 270 hypermethylated sites (e.g., cg09555818 located in APOC2) and 7437 sites hypomethylated sites (e.g., cg26828689 located in SLC12A5). Six DML were validated by pyrosequencing, and it was confirmed that DNA methylation (cg16391727, cg21008208, cg21293749, and cg13945576) was related to the increasing risk of AR. The relative mRNA expression of the ROR1 gene was also associated with AR (p = 0.007), suggesting that the change of cg21293749 in DNA methylation might lead to differential ROR1 mRNA expression, ultimately resulting in AR. Furthermore, the identified differentially methylated sites were associated with the molecular pathways such as circadian rhythms and insulin secretion. CONCLUSION Hence, the distinct DNA methylation might play a vital role in the biological regulation of AR through the pathways such as circadian rhythms.
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Affiliation(s)
- Qinglin Yu
- Department of Traditional Chinese Internal MedicineNingbo No. 1 HospitalNingboChina
| | - Jin Yang
- Department of GeriatricsNingbo No. 1 HospitalNingboChina
| | - Jiang Wang
- Department of CardiologyNingbo No.1 HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Ruoyan Yu
- Department of CardiologyNingbo No.1 HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Jiyi Li
- Department of CardiologyYuyao People's Hospital of Zhejiang ProvinceYuyaoChina
| | - Ji Cheng
- Department of Emergency, HwaMei HospitalUniversity of Chinese Academy of SciencesNingboChina
| | - Yingchu Hu
- Department of CardiologyNingbo No.1 HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Zhenwei Li
- Department of CardiologyNingbo No.1 HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Nan Zheng
- Department of Cardiology, HwaMei HospitalUniversity of Chinese Academy of SciencesNingboChina
| | - Zhaoxia Zhang
- Department of CardiologyNingbo No.1 HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Xiaojing Li
- Department of GeriatricsNingbo No. 1 HospitalNingboChina
| | - Yong Wang
- Department of CardiologyNingbo No.1 HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Weiping Du
- Department of CardiologyNingbo No.1 HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Keqi Zhu
- Department of Traditional Chinese Internal MedicineNingbo No. 1 HospitalNingboChina
| | - Xiaomin Chen
- Department of CardiologyNingbo No.1 HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
| | - Jia Su
- Department of CardiologyNingbo No.1 HospitalNingboChina,Key Laboratory of Precision Medicine for Atherosclerotic Diseases of Zhejiang ProvinceNingboChina
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Chen PL, Chen YJ, Chung CP, Seak CJ, Jeng JS, Hsieh MJ, Lien LM, Chen JH, Chen YW, Chiu TF, Lee JT, Ng CJ. Dual Antiplatelet Therapy in the Management of Acute Minor Ischemic Stroke and High-Risk Transient Ischemic Attack: An Expert Consensus Statement From Taiwan Stroke Society and Taiwan Society of Emergency Medicine. J Acute Med 2022; 12:85-95. [PMID: 36313610 PMCID: PMC9561483 DOI: 10.6705/j.jacme.202209_12(3).0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 07/24/2022] [Indexed: 06/16/2023]
Abstract
The aim of this review is to achieve a consensus between Taiwan Stroke Society (TSS) and Taiwan Society of Emergency Medicine (TSEM) to manage acute non-cardioembolic minor ischemic stroke (MIS) and high-risk transient ischemic attack (TIA). The methodology is to review the recent findings from clinical trials of dual antiplatelet therapy (DAPT) from 2010 to 2021 and updates in clinical practice guidelines from 2018 to 2022 for non-cardioembolic MIS/TIA management at the acute stage. Four leading clinical studies, CHANCE, POINT, THALES, and CHANCE-2 along with other relevant studies introducing DAPT, are discussed in this review. The risk-benefit profile between stroke recurrence reduction and major bleeding increase is also elucidated. TSS and TSEM concluded that for patients presenting with non-cardioembolic MIS or high-risk TIA who did not receive intravenous alteplase, initiation of DAPT within 24 hours after stroke onset and continued up to 21 days, followed by antiplatelet monotherapy, is effective in reducing recurrent ischemic stroke for a period of up to 90 days.
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Affiliation(s)
- Po-Lin Chen
- Neurological Institute Division of Neurology Taichung Veterans General Hospital, Taichung Taiwan
| | - Ying-Ju Chen
- Taipei Veterans General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Chih-Ping Chung
- Neurological Institute Department of Neurology Taipei Veterans General Hospital, Taipei Taiwan
| | - Chen-June Seak
- New Taipei Municipal Tucheng Hospital Department of Emergency Medicine New Taipei City Taiwan
- Chang Gung University College of Medicine Taoyuan Taiwan
| | - Jiann-Shing Jeng
- National Taiwan University Hospital Department of Neurology and Stroke Center Taipei Taiwan
| | - Ming-Ju Hsieh
- National Taiwan University Hospital Department of Emergency Medicine Taipei Taiwan
| | - Li-Ming Lien
- Shin Kong Wu Ho-Su Memorial Hospital Department of Neurology Taipei Taiwan
| | - Jiann-Hwa Chen
- Cathay General Hospital Department of Emergency Medicine Taipei Taiwan
| | - Yu-Wei Chen
- Landseed International Hospital Department of Neurology Taoyuan Taiwan
| | - Te-Fa Chiu
- China Medical University Hospital Department of Emergency Medicine Taichung Taiwan
| | - Jiunn-Tay Lee
- Tri-Service General Hospital Department of Neurology National Defense Medical Center, Taipei Taiwan
| | - Chip-Jin Ng
- Chang Gung University College of Medicine Taoyuan Taiwan
- Chang Gung Memorial Hospital Department of Emergency Medicine Linkou, Taoyuan Taiwan
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McDermott JH, Leach M, Sen D, Smith CJ, Newman WG, Bath PM. The role of CYP2C19 genotyping to guide antiplatelet therapy following ischemic stroke or transient ischemic attack. Expert Rev Clin Pharmacol 2022; 15:811-825. [PMID: 35912831 PMCID: PMC9612933 DOI: 10.1080/17512433.2022.2108401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction Clopidogrel is an antiplatelet agent recommended for secondary prevention of ischemic stroke (IS) and transient ischemic attack (TIA). Conversion of clopidogrel to its active metabolite by hepatic cytochrome P450-2C19 (CYP2C19) is essential for the inhibition of the P2Y12 receptor and subsequent platelet aggregation to prevent thrombotic events. CYP2C19 is highly polymorphic, with over 30 loss of function (LoF) alleles. This review considers whether there is sufficient data to support genotype guided antiplatelet therapy after stroke. Areas covered A systematic literature review retrieved articles, which describe the interaction between CYP2C19 genotype and clinical outcomes following IS or TIA when treated with clopidogrel. The review documents efforts to identify optimal antiplatelet regimens and explores the value genotype guided antiplatelet therapy. The work outlines the contemporary understanding of clopidogrel metabolism and appraises evidence linking CYP2C19 LoF variants with attenuated platelet inhibition and poorer outcomes. Expert opinion There is good evidence that CYP2C19 LoF allele carriers of Han-Chinese ancestry have increased risk for further vascular events following TIA or IS when treated with clopidogrel. The evidence base is less certain in other populations. The expansion of pharmacogenetics into routine clinical practice will facilitate further research and help tailor other aspects of secondary prevention.
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Affiliation(s)
- John H McDermott
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,The Division of Evolution, Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Marc Leach
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK
| | - Dwaipayan Sen
- Greater Manchester Comprehensive Stroke Centre, Geoffrey Jefferson Brain Research Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK
| | - Craig J Smith
- Greater Manchester Comprehensive Stroke Centre, Geoffrey Jefferson Brain Research Centre, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Salford, UK.,Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - William G Newman
- Manchester Centre for Genomic Medicine, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, M13 9WL, UK.,The Division of Evolution, Infection and Genomics, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK.,Stroke, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
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Xu Y, Chen W, Jiang L, Wang Y, Zhao X, Liu L, Yao D, Guo L, Wang Y, Pan Y, Wang Y. Aspirin platelet reactivity on platelet function and clinical outcome in minor stroke or transient ischemic attack. J Stroke Cerebrovasc Dis 2022; 31:106683. [PMID: 35914511 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/18/2022] [Accepted: 07/22/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Whether aspirin platelet reactivity affects platelet function and clinical outcomes with different antiplatelet therapies in patients with mild stroke or transient ischemic attack (TIA) remains unclear. We conducted a subgroup analysis of the PRINCE trial. MATERIALS AND METHODS Patients with mild stroke or TIA were randomized into aspirin+ticagrelor, or aspirin+clopidogrel groups; aspirin reaction units (ARU) were measured at the baseline and after 7 ± 2 days to assess response to treatment. High on-treatment platelet reactivity (HPR) was defined as ≥550 ARU (poor response to aspirin). The platelet functions of ticagrelor and clopidogrel were measured using the VerifyNow P2Y12 assay for P2Y12 reaction units (PRU); HPR to P2Y12 was defined as >208 PRU (poor response to P2Y12). Clinical outcomes included stroke and clinical vascular and bleeding events after 90 days. RESULTS Among 628 enrolled patients, 69 (11%) were poor aspirin responders. After 7 ± 2 days, the proportion of poor P2Y12 responders for ticagrelor versus clopidogrel significantly reduced in poor (2.6% versus 27.4%) and good (14.3% versus 29.4%) aspirin responders. There were significant interactions between treatment groups, and between treatment groups and aspirin platelet reactivity for poor P2Y12 responders (P = 0.01). After 90 ± 7 days, there were no significant interactions between treatment groups and aspirin platelet reactivity for new stroke risk (good aspirin responders: 5.5% versus 8.8%, hazard ratio [HR]: 0.61; 95% confidence interval [CI], 0.32 to 1.16; P = 0.13; poor aspirin responders: 8.6% versus 8.8%, HR: 0.97, 95% CI: 0.20-4.81; P = 0.97; P for interaction = 0.60). Major bleeding was less frequent in poor than good aspirin responders (ticagrelor/aspirin: 0.4%/0%; clopidogrel/aspirin: 1.4%/0%). CONCLUSIONS In patients with minor stroke or TIA, clopidogrel, and particularly ticagrelor, decreased platelet function in poor versus good aspirin responders. The poor platelet reactivity of aspirin could not sufficiently reduce the risk of recurrent stroke with ticagrelor or clopidogrel; however, HPR (poor aspirin response) may have a protective effect on clinically relevant major bleeding.
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Affiliation(s)
- Yanjie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China; Department of Neurology, Beijing Long Fu Hospital, Beijing, China
| | - Weiqi Chen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Lingling Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yicong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Dongxiao Yao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Lei Guo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No 119 South 4th Ring West Road, Fengtai District, Beijing 100070, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Advanced Innovation Center for Human Brain Protection, Capital Medical University, Beijing, China; Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
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Wang A, Meng X, Tian X, Johnston SC, Li H, Bath PM, Zuo Y, Xie X, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Wang F, Wang Y, Huang P, Chen G, Wang Y. Effect of Hypertension on Efficacy and Safety of Ticagrelor-Aspirin Versus Clopidogrel-Aspirin in Minor Stroke or Transient Ischemic Attack. Stroke 2022; 53:2799-2808. [PMID: 35656824 DOI: 10.1161/strokeaha.122.038662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hypertension is a risk factor of poor stroke outcomes and associated with antiplatelet resistance. This study aimed to explore the efficacy and safety of ticagrelor-aspirin versus clopidogrel-aspirin in patients with different hypertension status, using randomized trial data from the CHANCE-2 trial (Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events-II). METHODS A total of 6412 patients with minor stroke or transient ischemic attack who carried CYP2C19 loss-of-function alleles were enrolled and randomized to either ticagrelor-aspirin or clopidogrel-aspirin group. Hypertension status were classified into no, newly diagnosed, and previously diagnosed hypertension according to medical history, blood pressure, and antihypertensive medications during hospitalization. The primary efficacy and safety outcomes were stroke recurrence and moderate to severe bleeding risk within 90-day follow-up. RESULTS Ticagrelor-aspirin was associated with reduced risk of new stroke in patients without hypertension (32 [4.8%] versus 60 [7.2%]; hazard ratio, 0.55 [95% CI, 0.35-0.86]), but not in those with a newly diagnosed hypertension (20 [5.3%] versus 36 [9.1%]; hazard ratio 0.59 [95% CI, 0.33-1.07]), or those with a previously diagnosed hypertension (139 [7.0%] versus 147 [7.4%]; hazard ratio, 0.93 [95% CI, 0.74-1.18]) compared with clopidogrel-aspirin (P=0.04 for interaction). The risk of bleeding for ticagrelor-aspirin was not associated with hypertension status (0.1% versus 0.4%; 0.3% versus 0.5%, 0.4% versus 0.3%, P=0.50 for interaction). All the efficacy and safety outcomes between treatments did not differ by blood pressure levels on admission. CONCLUSIONS In the CHANCE-2 trial, patients without hypertension received a significantly greater benefit from ticagrelor- aspirin than those with previous hypertension after minor stroke or transient ischemic attack, and a similar benefit trend was observed in those with newly diagnosed hypertension. REGISTRATION URL: http://www. CLINICALTRIALS gov; Unique identifier: NCT04078737.
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Affiliation(s)
- Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Xue Tian
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (X.T., Y.Z.).,Beijing Municipal Key Laboratory of Clinical Epidemiology, China (X.T., Y.Z.)
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, United Kingdom (P.M.B.)
| | - Yingting Zuo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China (X.T., Y.Z.).,Beijing Municipal Key Laboratory of Clinical Epidemiology, China (X.T., Y.Z.)
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
| | - Feng Wang
- Departments of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, China (F.W.)
| | - Yanxia Wang
- Department of Neurology, Hejian People's Hospital, Hebei, China (Y.W.)
| | - Panbing Huang
- Department of Neurology, The third People's Hospital in Tongzhou District of Nantong, Jiangsu, China (P.H.)
| | - Guofang Chen
- Department of Neurology, Xuzhou Central Hospital, Jiangsu, China (G.C.)
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang).,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, China. (A.W., X.M., H.L., X.X., J.J., J.L., Yilong Wang, X.Z., Z.L., Y.J., L.L., Yongjun Wang)
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Passacquale G, Sharma P, Perera D, Ferro A. Antiplatelet therapy in cardiovascular disease: Current status and future directions. Br J Clin Pharmacol 2022; 88:2686-2699. [PMID: 35001413 PMCID: PMC9303765 DOI: 10.1111/bcp.15221] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022] Open
Abstract
Antiplatelet medications remain a cornerstone of therapy for atherosclerotic cardiovascular and cerebrovascular diseases. In primary prevention (patients with cardiovascular risk factors but no documented events, symptoms or angiographic disease), there is little evidence of benefit of any antiplatelet therapy, and such therapy carries the risk of excess bleeding. Where there is documented disease (secondary prevention), stable patients benefit from long-term antiplatelet monotherapy, aspirin being first choice in those with coronary heart disease and clopidogrel in those with cerebrovascular disease; moreover, recent evidence shows that low-dose rivaroxaban in combination with aspirin confers added benefit, in patients with stable cardiovascular and peripheral arterial disease. In patients with acute cerebrovascular disease, aspirin combined with clopidogrel reduces subsequent risk, while in acute coronary syndrome, dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) confers greater protection than aspirin monotherapy, with prasugrel and ticagrelor offering greater antiplatelet efficacy with faster onset of action than clopidogrel. Although greater antiplatelet efficacy is advantageous in preventing thrombotic events, this must be tempered by increased risk of bleeding, which may be a particular issue in certain patient groups, as will be discussed. We will also discuss possible future approaches to personalisation of antiplatelet therapy.
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Affiliation(s)
- Gabriella Passacquale
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research ExcellenceKing's College LondonLondonUK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal HollowayUniversity of LondonEghamSurreyUK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research ExcellenceKing's College LondonLondonUK
| | - Albert Ferro
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research ExcellenceKing's College LondonLondonUK
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Xie Q, Xiang Q, Liu Z, Mu G, Zhou S, Zhang Z, Ma L, Gong Y, Jiang J, Cui Y. Effect of CYP2C19 genetic polymorphism on the pharmacodynamics and clinical outcomes for patients treated with ticagrelor: a systematic review with qualitative and quantitative meta-analysis. BMC Cardiovasc Disord 2022; 22:111. [PMID: 35300607 PMCID: PMC8928616 DOI: 10.1186/s12872-022-02547-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/04/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Studies show inconsistent results regarding the impact of CYP2C19 genotype on the pharmacodynamics (PD) and clinical outcomes of ticagrelor. With the implementation of genotype-guided individualized antiplatelet therapy, the association between CYP2C19 polymorphism and the efficacy and safety of ticagrelor for patients is still worthy of exploring and studying. METHODS This systematic review protocol has been registered in the PROSPERO network (No. CRD 42020158920). Electronic databases of PubMed, EmBase, and the Cochrane Library were systematically searched from inception to January 6th, 2022 to select studies investigating the impact of CYP2C19 genotype on PD and clinical outcomes of ticagrelor. The results were presented as odds ratio (OR) or weight mean difference with its 95% confidence interval (CI) by using the random-effects model. Trial sequential analysis (TSA) was used to control risk of random errors and detect the robustness of outcomes. RESULTS Eight studies recruited a total of 6405 patients treated with ticagrelor. Mostly trials reported no significant effect of any or no CYP2C19 loss-of-function (LOF) allele (*2 or *3) on all the endpoints. Compared with no LOF allele carriers, subgroup analysis suggested any LOF allele in Asian patients was associated with a significant decreased risk of bleeding events (OR: 0.41; 95% CI: 0.22-0.75; P = 0.004). Furthermore, any LOF allele carriers didn't yield any impact on the risk of MACEs (OR: 1.11; 95% CI: 0.76-1.64; P = 0.586), stroke (OR: 1.71; 95% CI: 0.99-2.96; P = 0.054), definite stent thrombosis (OR: 0.88; 95% CI: 0.17-4.60; P = 0.882), bleeding (OR: 0.63; 95% CI: 0.27-1.46; P = 0.281), myocardial infarction (OR: 0.81; 95% CI: 0.30-2.20; P = 0.682), and revascularization (OR: 0.81; 95% CI: 0.33-2.00; P = 0.649) in all patients. The results of TSA were indicated that more further trials would be required. CONCLUSIONS This qualitative and quantitative study suggested Asian patients carrying any CYP2C19 LOF allele might have a lower risk of bleeding events comparing with no LOF allele carriers when treated with ticagrelor. However, we did not prove an important role of CYP2C19 genotype on the risk of PD and clinical endpoints in the whole cohort. In future, more large-scale prospective studies and more different ethnic populations should be included.
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Affiliation(s)
- Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Zhuo Zhang
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Lingyue Ma
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, No. 8, Xi Shi Ku Street, Beijing, 100034, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, No. 8, Xi Shi Ku Street, Beijing, 100034, China.
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China.
- Institue of Clinical Pharmacology, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
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Chen X, Xu J, Chen S, Dong Q, Dong Y. Dual antiplatelet therapy with ticagrelor may increase the risk of all bleeding events in patients with minor strokes or high risk TIAs: a meta-analysis. Stroke Vasc Neurol 2022; 7:271-275. [PMID: 35241629 PMCID: PMC9453826 DOI: 10.1136/svn-2021-001423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/19/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Xi Chen
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Jiawen Xu
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Shidong Chen
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Yi Dong
- Department of Neurology, Huashan Hospital Fudan University, Shanghai, China
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Matsumaru Y, Kitazono T, Kadota K, Nakao K, Nakagawa Y, Shite J, Yokoi H, Kozuma K, Tanabe K, Akasaka T, Shinke T, Ueno T, Hirayama A, Uemura S, Kuroda T, Takita A, Harada A, Iijima R, Murakami Y, Saito S, Nakamura M. Relationship between platelet aggregation and stroke risk after percutaneous coronary intervention: a PENDULUM analysis. Heart Vessels 2022; 37:942-953. [PMID: 34973085 PMCID: PMC9114031 DOI: 10.1007/s00380-021-02003-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/26/2021] [Indexed: 11/26/2022]
Abstract
In patients undergoing percutaneous coronary intervention (PCI) with a stent, high on-treatment platelet reactivity may be associated with an increased risk of stroke. This post hoc analysis of the PENDULUM registry compared the risk of post-PCI stroke according to on-treatment P2Y12 reaction unit (PRU) values. Patients aged ≥ 20 years who underwent PCI were stratified by baseline PRU (at 12 and 48 h post-PCI) as either high (HPR, > 208), optimal (OPR, > 85 to ≤ 208), or low on-treatment platelet reactivity (LPR, ≤ 85). The incidences of non-fatal ischemic and non-ischemic stroke through to 12 months post-PCI were recorded. Almost all enrolled patients (6102/6267 [97.4%]) had a risk factor for ischemic stroke, and most were receiving dual antiplatelet therapy. Of the 5906 patients with PRU data (HPR, n = 2227; OPR, n = 3002; LPR, n = 677), 47 had a non-fatal stroke post-PCI (cumulative incidence: 0.68%, ischemic; 0.18%, non-ischemic stroke). Patients with a non-fatal ischemic stroke event had statistically significantly higher post-PCI PRU values versus those without an event (P = 0.037). The incidence of non-fatal non-ischemic stroke was not related to PRU value. When the patients were stratified by PRU ≤ 153 versus > 153 at 12–48 h post-PCI, a significant difference was observed in the cumulative incidence of non-fatal stroke at 12 months (P = 0.044). We found that patients with ischemic stroke tended to have higher PRU values at 12–48 h after PCI versus those without ischemic stroke. Clinical trial registration: UMIN000020332.
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Affiliation(s)
- Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
| | - Takanari Kitazono
- Department of Clinical Medicine, National University Corporation Kyushu University, Fukuoka, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Okayama, Japan
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Junya Shite
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Hiroyoshi Yokoi
- Cardiovascular Medicine Center, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Ken Kozuma
- Division of Cardiology, Department of Internal Medicine, Teikyo University, Tokyo, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Takafumi Ueno
- Department of Cardiovascular Medicine, Fukuoka Kinen Hospital, Fukuoka, Japan
| | | | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School, Okayama, Japan
| | - Takeshi Kuroda
- Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Atsushi Takita
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Atsushi Harada
- Medical Information Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Raisuke Iijima
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yoshitaka Murakami
- Department of Medical Statistics, School of Medicine, Toho University, Tokyo, Japan
| | - Shigeru Saito
- Division of Cardiology and Catheterization Laboratories, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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Wang Y, Meng X, Wang A, Xie X, Pan Y, Johnston SC, Li H, Bath PM, Dong Q, Xu A, Jing J, Lin J, Niu S, Wang Y, Zhao X, Li Z, Jiang Y, Li W, Liu L, Xu J, Chang L, Wang L, Zhuang X, Zhao J, Feng Y, Man H, Li G, Wang B. Ticagrelor versus Clopidogrel in CYP2C19 Loss-of-Function Carriers with Stroke or TIA. N Engl J Med 2021; 385:2520-2530. [PMID: 34708996 DOI: 10.1056/nejmoa2111749] [Citation(s) in RCA: 149] [Impact Index Per Article: 49.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Comparisons between ticagrelor and clopidogrel for the secondary prevention of stroke in CYP2C19 loss-of-function carriers have not been extensively performed. METHODS We conducted a randomized, double-blind, placebo-controlled trial at 202 centers in China involving patients with a minor ischemic stroke or transient ischemic attack (TIA) who carried CYP2C19 loss-of-function alleles. Patients were assigned within 24 hours after symptom onset, in a 1:1 ratio, to receive ticagrelor (180 mg on day 1 followed by 90 mg twice daily on days 2 through 90) and placebo clopidogrel or to receive clopidogrel (300 mg on day 1 followed by 75 mg once daily on days 2 through 90) and placebo ticagrelor; both groups received aspirin for 21 days. The primary efficacy outcome was new stroke, and the primary safety outcome was severe or moderate bleeding, both within 90 days. RESULTS A total of 11,255 patients were screened and 6412 patients were enrolled, with 3205 assigned to the ticagrelor group and 3207 to the clopidogrel group. The median age of the patients was 64.8 years, and 33.8% were women; 98.0% belonged to the Han Chinese ethnic group. Stroke occurred within 90 days in 191 patients (6.0%) in the ticagrelor group and 243 patients (7.6%) in the clopidogrel group (hazard ratio, 0.77; 95% confidence interval, 0.64 to 0.94; P = 0.008). Secondary outcomes were generally in the same direction as the primary outcome. Severe or moderate bleeding occurred in 9 patients (0.3%) in the ticagrelor group and in 11 patients (0.3%) in the clopidogrel group; any bleeding occurred in 170 patients (5.3%) and 80 patients (2.5%), respectively. CONCLUSIONS Among Chinese patients with minor ischemic stroke or TIA who were carriers of CYP2C19 loss-of-function alleles, the risk of stroke at 90 days was modestly lower with ticagrelor than with clopidogrel. The risk of severe or moderate bleeding did not differ between the two treatment groups, but ticagrelor was associated with more total bleeding events than clopidogrel. (Funded by the Ministry of Science and Technology of the People's Republic of China and others; CHANCE-2 ClinicalTrials.gov number, NCT04078737.).
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Affiliation(s)
- Yongjun Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xia Meng
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Anxin Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xuewei Xie
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuesong Pan
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - S Claiborne Johnston
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Hao Li
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Philip M Bath
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Qiang Dong
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Anding Xu
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jing Jing
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinxi Lin
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Siying Niu
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yilong Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xingquan Zhao
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Zixiao Li
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yong Jiang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Wei Li
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Liping Liu
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jie Xu
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Liguo Chang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Lihua Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xianbo Zhuang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinguo Zhao
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yefang Feng
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Honghao Man
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Guozhong Li
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Baojun Wang
- From the China National Clinical Research Center for Neurological Diseases (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), the Department of Neurology (Yongjun Wang, X.M., A.W., X.X., Y.P., H.L., J.J., J.L., S.N., Yilong Wang, X. Zhao, Z.L., Y.J., W.L., L.L., J.X.), and the Advanced Innovation Center for Human Brain Protection (Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, and the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), Beijing, the Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai (Q.D.), the Department of Neurology, First Affiliated Hospital of Jinan University, Guangzhou (A.X.), the Department of Neurology, Third People's Hospital of Liaocheng (L.C.), and the Department of Neurology, Liaocheng People's Hospital (X. Zhuang), Liaocheng, the Department of Neurology, Second Affiliated Hospital of Harbin Medical University (L.W.), and the Department of Neurology, First Affiliated Hospital of Harbin Medical University (G.L.), Harbin, the Department of Neurology, Weihai Wendeng District People's Hospital (J.Z.), and the Department of Neurology, Weihai Central Hospital (H.M.), Weihai, the Department of Neurology, Second People's Hospital of Huludao, Huludao (Y.F.), and the Department of Neurology, Baotou Central Hospital, Baotou (B.W.) - all in China; Dell Medical School, University of Texas at Austin, Austin (S.C.J.); and the Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
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47
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Wang A, Meng X, Tian X, Johnston SC, Li H, Bath PM, Zuo Y, Xie X, Jing J, Lin J, Wang Y, Zhao X, Li Z, Jiang Y, Liu L, Wang F, Li Y, Liu J, Wang Y. Bleeding Risk of Dual Antiplatelet Therapy after Minor Stroke or TIA. Ann Neurol 2021; 91:380-388. [PMID: 34951042 DOI: 10.1002/ana.26287] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To identify the risk of bleeding events and potential risk factors within 90 days in patients carried CYP2C19 loss-of-function alleles and received dual antiplatelet therapy after minor stroke or transient ischemic attack. METHODS A total of 6,412 patients were enrolled from the Clopidogrel with aspirin in High-risk patients with Acute Non-disabling Cerebrovascular Events II (CHANCE-2) trial. The main outcome was any bleeding within 90 days defined by the criteria from Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO). RESULTS A total of 250 (3.9%) bleeding events were reported, which occurred mainly within the 21 days of dual antiplatelet therapy (200 cases, 3.1%). Minor bleeding of the skin bruises, epistaxis, and gum bleeding was most frequent. Multivariate analysis showed that treatment with ticagrelor-aspirin compared with clopidogrel-aspirin was associated with increased bleeding (hazard ratio [HR], 2.21; 95% confidence interval [CI], 1.68-2.89; P<0.001). Current smoking was associated with a lower risk of bleeding (HR, 0.70; 95% CI, 0.52-0.95; P=0.02). Additionally, ticagrelor-aspirin compared with clopidogrel-aspirin was associated with higher risk of bleeding in patients aged <65 years (HR, 2.87; 95% CI, 1.95-4.22) and those without diabetes mellitus (HR, 2.65; 95% CI, 1.88-3.73) (P for interaction=0.04 and 0.03, respectively). INTERPRETATION Bleeding events mostly occurred within the 21-day dual antiplatelet therapy stage and were generally mild. The risk of bleeding was greater in non-smoking patients, and was associated with treatment with ticagrelor-aspirin compared with clopidogrel-aspirin particularly in aged <65 years and non-diabetic patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xue Tian
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | | | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Yingting Zuo
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.,Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Xuewei Xie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jinxi Lin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Wang
- Departments of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ying Li
- Department of Neurology, Suixian Chinese Medicine Hospital, Henan, China
| | - Jingyao Liu
- Department of Neurology, First Hospital of Jilin University, Jilin, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Advanced Innovation Center for Human Brain Protection, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Ghamraoui AK, Chang H, Maldonado TS, Ricotta JJ. Clopidogrel Versus Ticagrelor for Antiplatelet Therapy in Transcarotid Artery Revascularization (TCAR) in the Society for Vascular Surgery Vascular Quality Initiative. J Vasc Surg 2021; 75:1652-1660. [PMID: 34920001 DOI: 10.1016/j.jvs.2021.11.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 11/11/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Transcarotid artery revascularization (TCAR) with dynamic flow reversal is a hybrid technique for operative management of carotid artery stenosis. Dual antiplatelet therapy is recommended for patients undergoing TCAR; however, nonresponders to these medications may be predisposed to perioperative thromboembolic complications. Prevalent in up to 44-66% of patients taking clopidogrel, high on-treatment platelet reactivity (HTPR) may thus be responsible for a portion of adverse cerebrovascular events in TCAR. A previous single-institution study has demonstrated the use of ticagrelor as a viable alternative to clopidogrel for antiplatelet therapy in patients undergoing TCAR; however, large-scale comparisons between clopidogrel and ticagrelor are needed to confirm the safety of ticagrelor outside of highly selected patients and providers. METHODS Data from patients enrolled in the Society for Vascular Surgery Vascular Quality Initiative undergoing TCAR with a perioperative antiplatelet therapy regimen including either clopidogrel or ticagrelor from January 2015 to March 2021 were analyzed and compared. Multivariable logistic regression and propensity score matching were used to evaluate the primary 30-day outcomes of stroke, major bleeding event, and combined stroke/myocardial infarction (MI)/death rate while adjusting for baseline characteristics of the patients. RESULTS A total of 11973 patients underwent TCAR with a dual antiplatelet therapy regimen that included clopidogrel versus 426 patients with ticagrelor. Compared to clopidogrel, patients on ticagrelor were significantly more likely to have coronary artery disease (51% vs 66% [P = <.001]), particularly unstable angina or MI within 6 months (3% vs 9% [P = <.001]), and more likely to have insulin-dependent diabetes mellitus (14% vs 19% [P = <.001]). The unadjusted 30-day rates of stroke, major bleeding, and combined stroke/MI/death were not statistically significant among both groups (1.3% vs 0.5% [P = .14], 2.4% vs 1.4% [P = .18], and 1.9% vs 1.6% [P = .71], respectively). After multivariable adjustment and propensity matching, these remained statistically insignificant. CONCLUSIONS Despite a substantially higher medical risk in patients undergoing TCAR with ticagrelor, 30-day rates of stroke, major bleeding events, and combined stroke/MI/death were similar between patients on ticagrelor and clopidogrel as part of adjunctive antiplatelet therapy. Randomized prospective trials, and studies with larger sample sizes and longer follow-up will be needed to better examine the outcome differences in TCAR between these two medications.
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Affiliation(s)
- Ahmed K Ghamraoui
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Heepeel Chang
- Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Thomas S Maldonado
- The Schwartz Buckely Professor of Surgery, NYU Langone Health, New York, NY, USA; Director of the Venous Thromboembolic Center and Aortic Center, NYU Langone Medical Center, New York, NY, USA
| | - Joseph J Ricotta
- National Director of Vascular Surgery and Endovascular Therapy, Tenet Healthcare Corporation, Delray Medical Center, Delray Beach, FL, USA; Professor of Surgery and Program Director, Vascular Surgery Fellowship, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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49
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Lun R, Dhaliwal S, Zitikyte G, Roy DC, Hutton B, Dowlatshahi D. Comparison of Ticagrelor vs Clopidogrel in Addition to Aspirin in Patients With Minor Ischemic Stroke and Transient Ischemic Attack: A Network Meta-analysis. JAMA Neurol 2021; 79:141-148. [PMID: 34870698 DOI: 10.1001/jamaneurol.2021.4514] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin is effective in preventing recurrent strokes after minor ischemic stroke or transient ischemic attack (TIA). However, there is emerging evidence for the use of ticagrelor and aspirin, and the 2 DAPT regimens have not been compared directly. Objective To compare ticagrelor and aspirin with clopidogrel and aspirin in patients with acute minor ischemic stroke or TIA in the prevention of recurrent strokes or death. Data Sources MEDLINE, Embase, and Cochrane from database inception until February 2021. Study Selection Randomized clinical trials that enrolled adults with acute minor ischemic stroke or TIA and provided the mentioned interventions within 72 hours of symptom onset, with a minimum follow-up of 30 days. Data Extraction and Synthesis PRISMA guidelines for network meta-analyses were followed. Two reviewers independently extracted data and appraised risk of bias. Fixed-effects models were fit using a bayesian approach to network meta-analysis. Between-group comparisons were estimated using hazard ratios (HRs) with 95% credible intervals (95% CrIs). Surface under the cumulative rank curve plots were produced. Main Outcomes and Measures The primary outcome was a composite of recurrent stroke or death up to 90 days. Secondary outcomes include major bleeding, mortality, adverse events, and functional disability. A sensitivity analysis was performed at 30 days for the primary outcome. Results A total of 4014 citations were screened; 5 randomized clinical trials were included. Data from 22 098 patients were analyzed, including 5517 in the clopidogrel and aspirin arm, 5859 in the ticagrelor and aspirin arm, and 10 722 in the aspirin arm. Both clopidogrel and aspirin (HR, 0.74; 95% CrI, 0.65-0.84) and ticagrelor and aspirin (HR, 0.79; 95% CrI, 0.68-0.91) were superior to aspirin in the prevention of recurrent stroke and death. There was no statistically significant difference between clopidogrel and aspirin compared with ticagrelor and aspirin (HR, 0.94; 95% CrI, 0.78-1.13). Both DAPT regimens had higher rates of major hemorrhage than aspirin alone. Clopidogrel and aspirin was associated with a decreased risk of functional disability compared with aspirin alone (HR, 0.82; 95% CrI, 0.74-0.91) and ticagrelor and aspirin (HR, 0.85; 95% CrI, 0.75-0.97). Conclusions and Relevance DAPT combining aspirin with either ticagrelor or clopidogrel was superior to aspirin alone, but there was no statistically significant difference found between the 2 regimens for the primary outcome.
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Affiliation(s)
- Ronda Lun
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada.,Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Shan Dhaliwal
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Gabriele Zitikyte
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Danielle Carole Roy
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada
| | - Brian Hutton
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- University of Ottawa School of Epidemiology and Public Health, Ottawa, Ontario, Canada.,Division of Neurology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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50
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Pang CH, Cho WS, Kang HS, Kim JE. Benefits and risks of antiplatelet medication in hemodynamically stable adult moyamoya disease. Sci Rep 2021; 11:19367. [PMID: 34588601 PMCID: PMC8481560 DOI: 10.1038/s41598-021-99009-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/17/2021] [Indexed: 12/13/2022] Open
Abstract
Revascularization surgery is considered a standard treatment for preventing additional stroke in symptomatic moyamoya disease (MMD). In hemodynamically stable, and asymptomatic or mildly symptomatic patients, however, the treatment strategy is controversial because of the obscure natural course of them. The authors analyzed the benefits and risks of antiplatelet medication in those patients. Medical data were retrospectively reviewed in 439 hemispheres of 243 patients with stable hemodynamic status. Overall, 121 patients (49.8%) with 222 studied hemispheres (50.6%) took antiplatelet medication. Symptomatic cerebral infarction and hemorrhage occurred in 10 (2.3%) and 30 (6.8%) hemispheres, over a mean follow-up of 62.0 ± 43.4 months (range 6-218 months). The use of antiplatelet agents was statistically insignificant in terms of symptomatic infarction, hemorrhage and improvement of ischemic symptoms. In subgroup analyses within the antiplatelet group according to drug potency and duration of medication, a longer duration of antiplatelet medication significantly improved ischemic symptoms (adjusted OR 1.02; 95% CI 1.01-1.03; p = 0.006). Antiplatelet medication failed to prevent symptomatic cerebral infarction or improve ischemic symptoms. However, antiplatelet therapy did not increase the risk of cerebral hemorrhage.
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Affiliation(s)
- Chang Hwan Pang
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
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