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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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Elmashad A, Emmerson D, Gorseth A, Jaffa MN. Ticagrelor Induced Angioedema Following Carotid Artery Stenting. Neurohospitalist 2022; 12:550-552. [DOI: 10.1177/19418744221097353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Ticagrelor is a frequent component of dual antiplatelet therapy (DAPT) following carotid artery stent placement. Hemorrhagic complications remain the focus of most reports, however, other adverse events must also be known to the prescribing physician. Angioedema is a rare and potentially life-threatening complication reported following ticagrelor administration and we present 1 such case here with a review of the existing literature.
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Affiliation(s)
- Ahmed Elmashad
- Department of Neurology, University of Connecticut, Farmington, CT, USA
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Danison Emmerson
- Department of Neurology, University of Connecticut, Farmington, CT, USA
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
| | - Allison Gorseth
- Department of Pharmacy Services, Hartford Hospital, Hartford, CT, USA
| | - Matthew N. Jaffa
- Department of Neurology, Ayer Neuroscience Institute, Hartford Hospital, Hartford, CT, USA
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Kargiotis O, Tsivgoulis G. The 2020 breakthroughs in early secondary prevention: dual antiplatelet therapy versus single antiplatelet therapy. Curr Opin Neurol 2021; 34:45-54. [PMID: 33196579 DOI: 10.1097/wco.0000000000000878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Single antiplatelet therapy represents an established treatment in secondary prevention of ischemic strokes and transient ischemic attacks (TIAs). In contrast with coronary artery disease, the use of dual antiplatelet therapy (DAPT) for secondary prevention in patients with acute cerebral ischemia (ACI) remains under debate. In this narrative review, we present and analyse the most recent findings concerning the potential efficacy and safety of DAPT therapy after ischemic strokes or TIA. RECENT FINDINGS Following the publication of the three (CHANCE, POINT and THALES) large, randomized-controlled, clinical trials (RCTs) that showed efficacy of early DAPT for the secondary prevention after minor AIS or TIA, short-term DAPT use is becoming the most prevalent choice of treatment. Notably, DAPT is even more popular after AIS attributed to large artery atherosclerosis given randomized data from small RCTs supporting the use of DAPT in patients with extracranial or intracranial atherosclerosis and microembolization detected by transcranial Doppler. Recent subanalysis of data from the randomized trials aim to identify specific patient subgroups, which are determined by genetic, imaging or clinical characteristics, and for whom DAPT appears to be more beneficial. The potential role of different antiplatelet agents (aspirin, clopidogrel, ticagrelor) is also discussed. SUMMARY DAPT has recently proven its efficacy for the early secondary prevention of AIS patients with minor stroke severity and high-risk TIA patients. However, the length of DAPT is still controversial, as well as the individualized selection of AIS or TIA patients with the lower risk of bleeding and with the greater benefit in prevention of ischemic cerebrovascular and cardiovascular events.
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Affiliation(s)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Poppe AY, Jacquin G, Roy D, Stapf C, Derex L. Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions. AJNR Am J Neuroradiol 2020; 41:1142-1148. [PMID: 32499251 DOI: 10.3174/ajnr.a6582] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/17/2020] [Indexed: 11/07/2022]
Abstract
Approximately 15% of patients undergoing endovascular thrombectomy for anterior circulation acute ischemic stroke have a tandem lesion, defined as a severe stenosis or occlusion of the cervical internal carotid artery ipsilateral to its intracranial occlusion. Patients with tandem lesions have worse outcomes than patients with isolated intracranial occlusions, but the optimal management of their carotid lesions during endovascular thrombectomy remains controversial. The main options commonly used in current practice include acute stent placement in the carotid lesion versus thrombectomy alone without definitive revascularization of the carotid artery. While treatment decisions for these patients are often complex and strategies vary according to clinical, anatomic, and technical considerations, only results from randomized trials comparing these approaches are likely to strengthen current recommendations and optimize patient care.
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Affiliation(s)
- A Y Poppe
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.) .,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - G Jacquin
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - D Roy
- Radiology (Neuroradiology) (D.R.), Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - C Stapf
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - L Derex
- Stroke Center (L.D.), Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, Lyon, France.,EA 7425 HESPER (L.D.), Health Services and Performance Research, Claude Bernard Lyon 1 University, Lyon, France
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Farrokh S, Owusu K, Lara LR, Nault K, Hui F, Spoelhof B. Neuro-Interventional Use of Oral Antiplatelets: A Survey of Neuro-Endovascular Centers in the United States and Review of the Literature. J Pharm Pract 2019; 34:207-215. [PMID: 31327286 DOI: 10.1177/0897190019854868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intra- and postprocedural thrombosis are major complication of aneurysmal coil embolization, stent-assisted coiling, and pipeline embolization. The common but unproven practice of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in neuro-endovascular patients is inferred from the cardiology literature without large clinical trials to support it in neuro-endovascular patients. OBJECTIVE We conducted an electronic survey to identify practice variations surrounding the use of oral antiplatelets in patients undergoing endovascular neuro-interventional procedures across neuro-endovascular centers in the United States. METHODS An electronic survey was distributed via the Web. Any practicing neuro-intensive care unit (ICU), neuro-interventional or stroke physician, pharmacist, physician assistant, or nurse practitioner was eligible to respond to this survey between June and October 2017. RESULTS A total of 33 responses were collected during the survey period. A response rate of 16% was calculated after taking into account all comprehensive stroke centers in the United States. Aspirin and clopidogrel was the standard-of-care antiplatelet regimen utilized in the majority of institutions (82%). Alternatively, 4 institutions used monotherapy (aspirin [n = 2], clopidogrel [n = 1], either aspirin or clopidogrel [n = 1]) and 2 institutions reported practitioner-dependent practices. Just under half of the centers reported ticagrelor as the primary alternative in clopidogrel nonresponders (48%). CONCLUSION Dual antiplatelet therapy with aspirin and clopidogrel appears to be standard of care in this setting based on our survey. About half of responding institutions use ticagrelor in cases where clopidogrel resistance is suspected. Large society-wide patient registries are needed to provide data for future safety and efficacy studies.
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Affiliation(s)
- Salia Farrokh
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Kent Owusu
- Department of Pharmacy, Yale-New Haven Hospital, New Haven, CT, USA
| | | | - Katharine Nault
- Department of Pharmacy, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Ferdinand Hui
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Brian Spoelhof
- Department of Pharmacy, Boston Medical Center, Boston, MA, USA
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Lamanna A, Maingard J, Barras CD, Kok HK, Handelman G, Chandra RV, Thijs V, Brooks DM, Asadi H. Carotid artery stenting: Current state of evidence and future directions. Acta Neurol Scand 2019; 139:318-333. [PMID: 30613950 DOI: 10.1111/ane.13062] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/18/2018] [Accepted: 01/03/2019] [Indexed: 11/29/2022]
Abstract
Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) are common treatments for carotid artery stenosis. Several randomized controlled trials (RCTs) have compared CEA to CAS in the treatment of carotid artery stenosis. These studies have suggested that CAS is more strongly associated with periprocedural stroke; however, CEA is more strongly associated with myocardial infarction. Published long-term outcomes report that CAS and CEA are similar. A reduction in complications associated with CAS has also been demonstrated over time. The symptomatic status of the patient and history of previous CEA or cervical radiotherapy are significant factors when deciding between CEA or CAS. Numerous carotid artery stents are available, varying in material, shape and design but with minimal evidence comparing stent types. The role of cerebral protection devices is unclear. Dual antiplatelet therapy is typically prescribed to prevent in-stent thrombosis, and however, evidence comparing periprocedural and postprocedural antiplatelet therapy is scarce, resulting in inconsistent guidelines. Several RCTs are underway that will aim to clarify some of these uncertainties. In this review, we summarize the development of varying techniques of CAS and studies comparing CAS to CEA as treatment options for carotid artery stenosis.
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Affiliation(s)
- Anthony Lamanna
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Julian Maingard
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
| | - Christen D. Barras
- South Australian Health and Medical Research Institute Adelaide South Australia Australia
- The University of Adelaide Adelaide South Australia Australia
| | - Hong Kuan Kok
- Interventional Radiology ServiceNorthern Hospital Radiology Melbourne, Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
| | - Guy Handelman
- Education and Research CentreBeaumont Hospital Dublin Ireland
- Department of RadiologyRoyal Victoria Hospital Belfast UK
| | - Ronil V. Chandra
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
| | - Vincent Thijs
- Stroke Division, The Florey Institute of Neuroscience & Mental HealthUniversity of Melbourne Melbourne Victoria Australia
- The University of Melbourne Melbourne Victoria Australia
- Department of NeurologyAustin Health Melbourne Victoria Australia
| | - Duncan Mark Brooks
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
| | - Hamed Asadi
- Interventional Radiology Service, Department of Radiology Austin Hospital Melbourne Victoria Australia
- School of Medicine, Faculty of HealthDeakin University Waurn Ponds Victoria Australia
- Department of ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Unit, Monash ImagingMonash Health Melbourne Victoria Australia
- Interventional Neuroradiology Service, Department of RadiologyAustin Hospital Melbourne Victoria Australia
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