Two-State Kinetic Model of Rates of Stroke Recurrence in the POINT Study Population

Predictors of very early stroke recurrence in the POINT trial population

Background

Recent trials of acute secondary prevention in patients with minor ischemic stroke or transient ischemic attack (TIA) have demonstrated high rates of early recurrence within days of the initial event. Identifying clinical features associated with early recurrence may guide focused management.

Methods

Using logistic regression applied to the data of the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial, we evaluated what baseline clinical factors predict outcome events occurring within 7 days of randomization.

Results

In the POINT trial, 181 subjects (3.7%) had early recurrence, defined as primary outcome events within 7 days of trial entry, whereas only 100 outcome events occurred over the remainder of the 90 day trial. Protective effects of dual antiplatelet therapy with clopidogrel plus aspirin were seen only as a reduction in these early recurrences, without any impact on later events. In univariate analysis, systolic blood pressure, diastolic blood pressure, serum glucose, initial carotid imaging results, study cohort (minor stroke or TIA), and treatment assignment were significantly associated with early recurrence. Multivariate logistic regression analysis identified a number of factors with significant independent associations with early recurrence, including carotid stenosis or occlusion (Odds Ratio [OR] 2.77; 95% confidence interval [CI] 1.78–4.31), cohort (minor stroke versus TIA) (OR 1.86; 95% CI 1.33–2.58), race (OR 1.57; 95% CI 1.10–2.25), baseline statin use (OR 0.68; 95% CI 0.49–0.95), systolic blood pressure (OR 1.10; 95% CI 1.03–1.18), serum glucose (OR 1.03; 95% CI 1.01–1.05), and age (OR 1.02; 95% CI 1.00–1.03). Receiver Operator Characteristic (ROC) analysis showed a 70% accuracy of the resulting logistic model in predicting early recurrence.

Conclusions

Early recurrence is high, and is concentrated in the first 7 days, in patients with minor stroke or TIA. A number of baseline clinical factors, including carotid disease, presentation with minor stroke rather than TIA, race, absence of statin usage, systolic blood pressure, and serum glucose, are independently associated with early event recurrence in the POINT trial population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02703-4.

Acute Secondary Prevention of Ischemic Stroke: Overlooked No Longer

Recent studies of interventions initiated acutely following onset of minor ischemic stroke or transient ischemic attack (TIA) have disclosed early stroke recurrence rates that are substantially higher than long-term recurrence rates and that can be reduced by acute antiplatelet treatment interventions. These observations, bolstered by analysis based on kinetic modeling of the time course of recurrence following initial events, suggest that acute stroke patients experience an underlying vulnerable state that quickly transitions to a more stable state. Some evidence also supports the benefits of early treatment with direct-acting oral anticoagulants in cardioembolic stroke and of continuation or early initiation of statin therapy in atherosclerotic stroke. Treatment of ischemic stroke should address the transient vulnerable state that follows the initial event, employing measures aiming to avert early recurrence of thromboembolism and to promote stabilization of vulnerable arterial plaque. These measures constitute acute secondary prevention following ischemic stroke.