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. 2023 Oct;54(10):2552-2561.
doi: 10.1161/STROKEAHA.123.043769. Epub 2023 Sep 7.

Determinants and Temporal Trends of Dual Antiplatelet Therapy After Mild Noncardioembolic Stroke

Victor J Del Brutto  1 , Ruijie Yin  1 , Hannah Gardener  1 , Hao Ying  1 , Carolina M Gutierrez  1 , Angus M Jameson  2 , David Z Rose  2 , Ayham Alkhachroum  1 , Dianne Foster  3 , Chuanhui Dong  1 , Selina Ancheta  4 , Nicole B Sur  1 , Gillian Gordon Perue  1 , Tatjana Rundek  1 , Negar Asdaghi  1 , Ralph L Sacco  1 , Jose G Romano  1
Affiliations

Determinants and Temporal Trends of Dual Antiplatelet Therapy After Mild Noncardioembolic Stroke

Victor J Del Brutto et al. Stroke. 2023 Oct.

Abstract

Background: Short-term dual antiplatelet therapy (DAPT) reduces early stroke recurrence after mild noncardioembolic ischemic stroke (NCIS). We aim to evaluate temporal trends and determinants of DAPT prescription after mild NCIS in the Florida Stroke Registry, a statewide registry across Get With The Guidelines-Stroke participating hospitals.

Methods: In this cross-sectional analysis of a cohort study, we included patients with mild NCIS (National Institutes of Health Stroke Scale score ≤3) who were potentially eligible for DAPT across 168 Florida Stroke Registry participating hospitals between January 2010 and September 2022. Using antiplatelet prescription as the dependent variable (DAPT versus single antiplatelet therapy), we fit logistic regression models adjusted for patient-related factors, hospital-related factors, clinical presentation, vascular risk factors, and ischemic stroke subtype, to obtain adjusted odds ratios (aORs) with 95% CIs.

Results: From 283 264 Florida Stroke Registry ischemic stroke patients during the study period, 109 655 NCIS were considered eligible. Among these, 37 058 patients with National Institutes of Health Stroke Scale score >3 were excluded, resulting in a sample of 72 597 mild NCIS (mean age 68±14 years; female 47.3%). Overall, 24 693 (34.0%) patients with mild NCIS were discharged on DAPT and 47 904 (66.0%) on single antiplatelet therapy. DAPT prescription increased from 25.7% in 2010 to 52.8% in 2022 (β/year 2.5% [95% CI, 1.5%-3.4%]). Factors associated with DAPT prescription were premorbid antiplatelet therapy (aOR, 4.66 [95% CI, 2.20-9.88]), large-artery atherosclerosis (aOR, 1.68 [95% CI, 1.43-1.97]), diabetes (aOR, 1.29 [95% CI, 1.13-1.47]), and hyperlipidemia (aOR, 1.24 [95% CI, 1.10-1.39]), whereas female sex (aOR, 0.83 [95% CI, 0.75-0.93]), being non-Hispanic Black patients (compared with non-Hispanic White patients; aOR, 0.78 [95% CI, 0.68-0.90]), admission to a Thrombectomy-capable Stroke Center (compared with Comprehensive Stroke Center; aOR, 0.78 [95% CI, 0.66-0.92]), time-to-presentation 1 to 7 days from last seen well (compared with <24 h; aOR, 0.86 [95% CI, 0.76-0.96]), and small-vessel disease stroke (aOR, 0.81 [95% CI, 0.72-0.94]) were associated with not receiving DAPT at discharge.

Conclusions: Despite a temporal trend increase in DAPT prescription after mild NCIS, we found substantial underutilization of evidence-based DAPT associated with significant disparities in stroke care.

Keywords: aspirin; atherosclerosis; clopidogrel; hyperlipidemia; ischemic stroke.

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Conflict of interest statement

Disclosures Drs Del Brutto and Yin receive research salary support from the Florida Stroke Registry (FSR) COHAN-R3. Drs Gardener, Hao, Gutierrez, and Rundek receive research salary support from the FSR COHAN-R2. Dr Rose received honoraria for consulting or speaker bureau from Atricure, Boston Scientific, Cheisi-USA, CSL-Behring, and Medtronic. Dr Alkhachroum is supported by KL2 Career Development Award from the Miami CTSI NCATS UL1TR002736 and by the National Institutes of Health/National Institute of Neurological Disorders and Stroke under Award Number K23NS126577 and R21NS128326. Dr Sur is supported by KL2 Career Development Award from the Miami CTSI NCATS KL2TR002737 and research salary support from the FSR COHAN-R3. Dr Asdaghi receives research salary support from the FSR COHAN-R2 and compensations from the American Heart Association for employment in Stroke editorial board. Dr Romano reports compensation from Genentech USA Inc. for data and safety monitoring services, stock holdings in Vycor Medical, and receives research salary support from the FSR COHAN-R2. The other authors report no conflicts.

Figures

Figure 1.
Figure 1.
Flow chart of the study population.
Figure 2.
Figure 2.
Time trends of the use of dual antiplatelet therapy after mild non-cardioembolic stroke in the Florida Stroke Registry population from January 2010 to September 2022; (A) All-inclusive analysis; (B) Subgroup of patients who presented <24 hours of last seen well.
See this image and copyright information in PMC

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