Long-Term Safety and Efficacy of Antiplatelet Therapy in Patients With Cerebral Infarction With Thrombocytopenia

Safety of Antiplatelet Therapy in Noncardioembolic Ischemic Stroke With Thrombocytopenia: The CASE II Study

BACKGROUND

There is scant evidence regarding the safety of antiplatelet therapy in acute ischemic stroke (AIS) patients with thrombocytopenia. Our study aims to address this concern by examining AIS patients with thrombocytopenia from a large database in real-world settings.

METHODS AND RESULTS

We included patients with AIS with a platelet count <100×109/L who had complete records of antiplatelet drug use. Those requiring anticoagulation or having contraindications to antiplatelet therapy were excluded. Short-term safety outcomes were in-hospital bleeding events, while the long-term safety outcome was 1-year all-cause mortality. A good clinical outcome was defined as functional independence, indicated by a modified Rankin Scale score of 0 to 2 at discharge. Propensity score matched analyses were used. We screened 169 423 patients with AIS from 90 stroke centers in the CASE II register, ultimately enrolling 2808 noncardioembolic patients with thrombocytopenia. In the propensity score matched analyses, no significant difference was observed between the antiplatelet and nonantiplatelet groups in terms of intracranial hemorrhage (odds ratio=0.855 [95% CI, 0.284-5.478]; P=0.160) or gastrointestinal bleeding (odds ratio=2.034 [95% CI, 0.755-5.478]; P=0.160). Antiplatelet therapy was associated with improved functional outcomes at discharge (odds ratio=1.405 [95% CI, 1.028-1.920]; P=0.033), and showed a trend towards reducing 1-year mortality (odds ratio=0.395 [95% CI, 0.152-1.031]; P=0.058).

CONCLUSIONS

The use of antiplatelet therapy lessened as platelet count decreased in patients with AIS with thrombocytopenia. However, our findings suggest that antiplatelet medications remain safe and effective for this population.

Safety of early antiplatelet therapy for non-cardioembolic mild stroke patients with thrombocytopenia

OBJECTIVES

To investigate the safety of early antiplatelet therapy for non-cardioembolic mild stroke patients with thrombocytopenia.

METHODS

Data of acute ischemic stroke patients with baseline National Institutes of Health Stroke Scale (NIHSS) score ≤3 and a platelet count <100×109/L were obtained from a multicenter register. Those who required anticoagulation or had other contraindications to antiplatelet therapy were excluded. Short-term safety outcomes were in-hospital bleeding events, while the long-term safety outcome was a 1-year all-cause death. The short-term neurological outcomes were evaluated by modified Rankin scale (mRS) score at discharge.

RESULTS

A total of 1868 non-cardioembolic mild stroke patients with thrombocytopenia were enrolled. Multivariate regression analyses showed that mono-antiplatelet therapy significantly increased the proportion of mRS score of 0-1 at discharge (OR=1.657, 95%CI: 1.253-2.192, P<0.01) and did not increase the risk of intracranial hemorrhage (OR=2.359, 95%CI: 0.301-18.503, P>0.05), compared with those without antiplatelet therapy. However, dual-antiplatelet therapy did not bring more neurological benefits (OR=0.923, 95%CI: 0.690-1.234, P>0.05), but increased the risk of gastrointestinal bleeding (OR=2.837, 95%CI: 1.311-6.136, P<0.01) compared with those with mono-antiplatelet therapy. For patients with platelet counts ≤75×109/L and >90×109/L, antiplatelet therapy significantly improved neurological functional outcomes (both P<0.05). For those with platelet counts (>75-90)×109/L, antiplatelet therapy resulted in a significant improvement of 1-year survival (P<0.05). For patients even with concurrent coagulation abnormalities, mono-antiplatelet therapy did not increase the risk of various types of bleeding (all P>0.05) but improved neurological functional outcomes (all P<0.01). There was no significant difference in the occurrence of bleeding events, 1-year all-cause mortality risk, and neurological functional outcomes between aspirin and clopidogrel (all P>0.05).

CONCLUSIONS

For non-cardioembolic mild stroke patients with thrombocytopenia, antiplatelet therapy remains a reasonable choice. Mono-antiplatelet therapy has the same efficiency as dual-antiplatelet therapy in neurological outcome improvement with lower risk of gastrointestinal bleeding.

Immune thrombocytopenia and risk of stroke: Evidence from a nationwide population-based cohort study

BACKGROUND

Research investigating differences in the overall stroke risk between individuals with and without immune thrombocytopenia (ITP) is lacking.

METHODS

This real-world study used the National Health Insurance Research Database (NHIRD). Risk of stroke was compared between 13,085 individuals with ITP enrolled between 1 January 2000 and 31 December 2015 and a control cohort of 52,340 individuals without ITP (1:4 ratio propensity score-matched by age, sex, index year, relevant comorbidities, and medications). Sub-distribution hazards models were used to estimate adjusted sub-distribution hazard ratio (SHR) and 95% confidence intervals (CIs), with the non-ITP group as the control group.

RESULTS

Of the 65,425 participants, 13,085 had ITP, 63.3% were women, and the mean age was 52.59 years. The risk of both ischemic and hemorrhagic stroke was 1.14 times (adjusted SHR 1.14, 95% CI, 1.07-1.22) and 1.93 times (adjusted SHR 1.93, 95% CI, 1.70-2.20) higher in the ITP group than in controls. Patients with ITP in the 20- to 29-year subgroup had a higher risk of new-onset stroke (adjusted SHR, 4.06 (95% CI, 2.72-6.07), p value for interaction <0.01) than those aged 20-29 years without ITP. Individuals with severe ITP with splenectomy had a 1.79 times higher overall stroke risk than those without.

CONCLUSIONS

ITP is associated with increased risk of both ischemic and hemorrhagic stroke.

Serum 4-hydroxynonenal associates with the recurrence of patients with primary cerebral infarction

Background

4-Hydroxynonenal (4-HNE), an α, β-unsaturated hydroxyalkenal, has been found to be associated with aspirin resistance, which is a risk factor for recurrent cerebral infarction. However, its effect on recurrent cerebral infarction is less defined. We designed this study to investigate the association between 4-HNE and increased risk of recurrent cerebral infarction.

Methods

We recruited 189 patients with primary cerebral infarction from 2017 to 2019. According to the recurrence of cerebral infarction during the 3-year follow-up period, they were divided into two groups, namely, the non-recurrence group (n = 93) and the recurrence group (n = 96). All patients were analyzed to explore the risk factors for the recurrence of primary cerebral infarction and the predictive value of serum 4-HNE for the recurrence of cerebral infarction.

Results

The levels of serum 4-HNE in patients of the recurrence group were significantly higher than that in patients of the non-recurrence group. There was a positive correlation between serum 4-HNE levels and the serum levels of triglyceride (r = 0.448, p = 0.008) and low-density lipoprotein cholesterol (LDL-C; r = 0.442, p = 0.002) in primary cerebral infarction patients. Cox proportional hazards modeling showed that demographic and certain clinical parameters, such as age, serum triglyceride levels, the National Institutes of Health Stroke Scale (NIHSS) scores, and serum 4-HNE levels, were independent factors for the recurrence in patients. The results of the receiver operating characteristic (ROC) curve showed that the area under the curve (AUC) value of serum 4-HNE in patients with cerebral infarction recurrence was 0.703, and when the cutoff value of serum 4-HNE was set at 42.34 ng/ml, the sensitivity and specificity values of serum 4-HNE in predicting recurrent cerebral infarction were 79.20 and 52.70%, respectively.

Conclusion

Serum 4-HNE is an independent risk factor for the recurrence of patients with primary cerebral infarction, and it may become a new intervention way to prevent the recurrence of patients with cerebral infarction.

Correlation Between Serum β2-GPI/oxLDL and the Risk of Cerebral Infarction in Patients with T2DM

Objective

This study aims to study the correlation between serum β2-glycoprotein I (β2-GPI)/oxidized low-density lipoprotein (oxLDL) and the risk of cerebral infarction in patients with type 2 diabetes (T2DM).

Methods

From January 2019 to March 2021, 56 patients with T2DM combined with cerebral infarction were chosen as a diabetic cerebral infarction (DCI) group, and 60 patients with simple T2DM were chosen as a T2DM group. In addition, 60 healthy volunteers were recruited as a control group. The essential information of each group was collected, and the serum β2-GPI/oxLDL and inflammatory factor levels in each group were compared. The clinical factors that affect the risk of ischemic cerebral infarction in patients with T2DM were analyzed by a logistic model.

Results

Compared with the control group, the level of serum β2-GPI/oxLDL in the T2DM and DCI groups increased significantly, P < 0.001. Compared with the T2DM group, the serum β2-GPI/oxLDL level in the DCI group increased significantly, P < 0.05. The result of Pearson’s correlation analysis showed that serum β2-GPI/oxLDL was positively correlated with total cholesterol, triglycerides, fasting blood glucose, 2-h postprandial blood glucose, glycosylated hemoglobin, interleukin-6, and tumor necrosis factor (TNF)-α (all P’s < 0.05). Serum TNF-α and β2-GPI/oxLDL were independent risk variates for DCI (P < 0.05). Based on the receiver operating characteristic curve analysis, the values of the area under the curve for TNF-α, serum β2-GPI/oxLDL, and the combined diagnosis of DCI were 0.653 (0.552–0.753), 0.680 (0.583–0.777), 0.739 (0.647–0.831), respectively.

Conclusion

In DCI patients, the levels of serum oxLDL/β2-GPI are significantly increased. Serum oxLDL/β2-GPI is an independent risk factor that affects the occurrence of DCI. In addition, the serum β2-GPI/oxLDL level implicates the lipid metabolism and inflammatory status of the internal environment of DCI patients to a certain extent.