Combining Intravenous Thrombolysis and Dual Antiplatelet Treatment in Patients With Minor Ischemic Stroke: A Propensity Matched Analysis of the READAPT Study Cohort

Abstract

Background: The optimal treatment for acute minor ischemic stroke is still undefined. and options include dual antiplatelet treatment (DAPT), intravenous thrombolysis (IVT), or their combination. We aimed to investigate benefits and risks of combining IVT and DAPT versus DAPT alone in patients with MIS.

Methods and results: This is a prespecified propensity score-matched analysis from a prospective multicentric real-world study (READAPT [Real-Life Study on Short-Term Dual Antiplatelet Treatment in Patients With Ischemic Stroke or Transient Ischemic Attack]). We included patients with MIS (National Institutes of Health Stroke Scale score at admission ≤5), without prestroke disability (modified Rankin scale [mRS] score ≤2). The primary outcomes were 90-day mRS score of 0 to 2 and ordinal mRS distribution. The secondary outcomes included 90-day risk of stroke and other vascular events and 24-hour early neurological improvement or deterioration (≥2-point National Institutes of Health Stroke Scale score decrease or increase from the baseline, respectively). From 1373 patients with MIS, 240 patients treated with IVT plus DAPT were matched with 427 patients treated with DAPT alone. At 90 days, IVT plus DAPT versus DAPT alone showed similar frequency of mRS 0 to 2 (risk difference, 2.3% [95% CI -2.0% to 6.7%]; P=0.295; risk ratio, 1.03 [95% CI 0.98-1.08]; P=0.312) but more favorable ordinal mRS scores distribution (odds ratio, 0.57 [95% CI 0.41-0.79]; P<0.001). Compared with patients treated with DAPT alone, those combining IVT and DAPT had higher 24-hour early neurological improvement (risk difference, 20.9% [95% CI 13.1%-28.6%]; risk ratio, 1.59 [95% CI 1.34-1.89]; both P<0.001) and lower 90-day risk of stroke and other vascular events (hazard ratio, 0.27 [95% CI 0.08-0.90]; P=0.034). There were no differences in safety outcomes.

Conclusions: According to findings from this observational study, patients with MIS may benefit in terms of better functional outcome and lower risk of recurrent events from combining IVT and DAPT versus DAPT alone without safety concerns.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05476081.

Keywords: dual antiplatelet treatment; functional outcome; intravenous thrombolysis; ischemic stroke; real world; safety.

Figure 1. Study flow diagram.

Patients may have ≥1 exclusion criterion. DAPT indicates dual antiplatelet treatment; EA, endarterectomy; EVT, endovascular thrombectomy; IVT, intravenous thrombolysis; mRS, modified Rankin scale; NIHSS, National Institute of Health Stroke Scale; and READAPT: Real‐Life Study on Short‐Term Dual Antiplatelet Treatment in Patients With Ischemic Stroke or Transient Ischemic Attack.

Figure 2. Ordinal distribution of 90‐day modified Rankin scale scores.

DAPT indicates dual antiplatelet treatment; and IVT, intravenous thrombolysis.

Figure 3. Kaplan–Meier cumulative hazard function of 90‐d risk of stroke and other cardiovascular events.

Dashed lines indicate 95% CIs. Log‐rank test P value=0.020. DAPT indicates dual antiplatelet treatment; and IVT, intravenous thrombolysis.