Intravenous Thrombolysis for Ischemic Stroke Patients on Dual Antiplatelets

Georgios Tsivgoulis (Corresponding Author), Aristeidis H. Katsanos, Dimitris Mavridis, Zuzana Gdovinova, Michal Karlinski, Mary Joan Macleod, Daniel Strbian, Niaz Ahmed

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

ObjectiveWe assessed the outcomes of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients on dual antiplatelet therapy prior to stroke onset.
MethodsWe analyzed prospectively collected data from the SITS International Stroke Thrombolysis Register (SITS‐ISTR) on consecutive IVT‐treated AIS patients during a seven‐year period (2010‐2017). In propensity‐score matched groups of patients with dual antiplatelet pretreatment and no antiplatelet pretreatment we compared: 1) SICH, according to SITS‐MOST, ECASS II and NINDS definitions, 2) 3‐month mortality, 3) 3‐month favorable functional outcome (FFO; mRS‐scores:0‐1), 4) 3‐month functional independence (FI; mRS‐scores:0‐2) and 5) distribution of the 3‐month mRS‐scores. Dual antiplatelet pretreatment was defined as all possible combinations among aspirin, clopidogrel, dipyridamole or any other antiplatelet.
ResultsPropensity‐score matching resulted in two groups of 1043 patients each, balanced for all baseline characteristics. In the propensity‐score matched analysis the two groups had comparable (p>0.017 using Bonferroni correction for multiple comparisons) SICH rates according to SITS‐MOST (2.9% vs. 1.5%; 95%CI:‐0.03,‐0.01), ECASS II (5.2% vs. 4.4%; 95%CI:‐0.03,0.01) and NINDS (7.7% vs. 6.6%; 95%CI:‐0.03,0.01) definitions. No differences in the 3‐month mortality (17.9% vs. 16.6%; 95%CI:‐0.05,0.02), FFO (45.6% vs. 46.0%; 95%CI:‐0.04,0.05), FI rates (59.2% vs. 60.7%; 95%CI:‐0.03,0.06) or the distribution in 3‐month mRS‐scores [2 (1‐4) vs. 2 (0‐4); 95%CI:‐0.29,0.09] were documented between the two groups.

Interpretation
Given that patients on dual antiplatelet pretreatment have similar SICH, 3‐month mortality rates and functional outcomes compared to patients with no antiplatelet pretreatment, dual antiplatelet pretreatment history should not be used as a reason to withhold IVT in otherwise eligible AIS patients.
Original languageEnglish
Pages (from-to)89-97
Number of pages9
JournalAnnals of Neurology
Volume84
Issue number1
Early online date30 Jul 2018
DOIs
Publication statusPublished - Jul 2018

Fingerprint

Stroke
National Institute of Neurological Disorders and Stroke
clopidogrel
Mortality
4-Acetamido-4'-isothiocyanatostilbene-2,2'-disulfonic Acid
Dipyridamole
Aspirin
Research Design
History
Therapeutics

Keywords

  • acute ischemic stroke
  • dual antiplatelet therapy
  • mortality
  • functional outcome
  • intracranial hemorrhage

Cite this

Tsivgoulis, G., Katsanos, A. H., Mavridis, D., Gdovinova, Z., Karlinski, M., Macleod, M. J., ... Ahmed , N. (2018). Intravenous Thrombolysis for Ischemic Stroke Patients on Dual Antiplatelets. Annals of Neurology, 84(1), 89-97. https://doi.org/10.1002/ana.25269

Intravenous Thrombolysis for Ischemic Stroke Patients on Dual Antiplatelets. / Tsivgoulis, Georgios (Corresponding Author); Katsanos, Aristeidis H.; Mavridis, Dimitris; Gdovinova, Zuzana; Karlinski, Michal; Macleod, Mary Joan; Strbian, Daniel; Ahmed , Niaz .

In: Annals of Neurology, Vol. 84, No. 1, 07.2018, p. 89-97.

Research output: Contribution to journalArticle

Tsivgoulis, G, Katsanos, AH, Mavridis, D, Gdovinova, Z, Karlinski, M, Macleod, MJ, Strbian, D & Ahmed , N 2018, 'Intravenous Thrombolysis for Ischemic Stroke Patients on Dual Antiplatelets', Annals of Neurology, vol. 84, no. 1, pp. 89-97. https://doi.org/10.1002/ana.25269
Tsivgoulis G, Katsanos AH, Mavridis D, Gdovinova Z, Karlinski M, Macleod MJ et al. Intravenous Thrombolysis for Ischemic Stroke Patients on Dual Antiplatelets. Annals of Neurology. 2018 Jul;84(1):89-97. https://doi.org/10.1002/ana.25269
Tsivgoulis, Georgios ; Katsanos, Aristeidis H. ; Mavridis, Dimitris ; Gdovinova, Zuzana ; Karlinski, Michal ; Macleod, Mary Joan ; Strbian, Daniel ; Ahmed , Niaz . / Intravenous Thrombolysis for Ischemic Stroke Patients on Dual Antiplatelets. In: Annals of Neurology. 2018 ; Vol. 84, No. 1. pp. 89-97.
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abstract = "ObjectiveWe assessed the outcomes of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients on dual antiplatelet therapy prior to stroke onset.MethodsWe analyzed prospectively collected data from the SITS International Stroke Thrombolysis Register (SITS‐ISTR) on consecutive IVT‐treated AIS patients during a seven‐year period (2010‐2017). In propensity‐score matched groups of patients with dual antiplatelet pretreatment and no antiplatelet pretreatment we compared: 1) SICH, according to SITS‐MOST, ECASS II and NINDS definitions, 2) 3‐month mortality, 3) 3‐month favorable functional outcome (FFO; mRS‐scores:0‐1), 4) 3‐month functional independence (FI; mRS‐scores:0‐2) and 5) distribution of the 3‐month mRS‐scores. Dual antiplatelet pretreatment was defined as all possible combinations among aspirin, clopidogrel, dipyridamole or any other antiplatelet.ResultsPropensity‐score matching resulted in two groups of 1043 patients each, balanced for all baseline characteristics. In the propensity‐score matched analysis the two groups had comparable (p>0.017 using Bonferroni correction for multiple comparisons) SICH rates according to SITS‐MOST (2.9{\%} vs. 1.5{\%}; 95{\%}CI:‐0.03,‐0.01), ECASS II (5.2{\%} vs. 4.4{\%}; 95{\%}CI:‐0.03,0.01) and NINDS (7.7{\%} vs. 6.6{\%}; 95{\%}CI:‐0.03,0.01) definitions. No differences in the 3‐month mortality (17.9{\%} vs. 16.6{\%}; 95{\%}CI:‐0.05,0.02), FFO (45.6{\%} vs. 46.0{\%}; 95{\%}CI:‐0.04,0.05), FI rates (59.2{\%} vs. 60.7{\%}; 95{\%}CI:‐0.03,0.06) or the distribution in 3‐month mRS‐scores [2 (1‐4) vs. 2 (0‐4); 95{\%}CI:‐0.29,0.09] were documented between the two groups.InterpretationGiven that patients on dual antiplatelet pretreatment have similar SICH, 3‐month mortality rates and functional outcomes compared to patients with no antiplatelet pretreatment, dual antiplatelet pretreatment history should not be used as a reason to withhold IVT in otherwise eligible AIS patients.",
keywords = "acute ischemic stroke, dual antiplatelet therapy, mortality, functional outcome, intracranial hemorrhage",
author = "Georgios Tsivgoulis and Katsanos, {Aristeidis H.} and Dimitris Mavridis and Zuzana Gdovinova and Michal Karlinski and Macleod, {Mary Joan} and Daniel Strbian and Niaz Ahmed",
note = "We thank all SITS-ISTR investigators and their centers for their participation. We also pass on our thanks to all patients who participated in SITS-ISTR. The current SITS registry is developed, maintained and upgraded by Zitelab, Copenhagen, Denmark, in close collaboration with SITS. SITS (Safe Implementation of Treatment in Stroke) is financed directly and indirectly by grants from Karolinska Institute, Stockholm County Council, the Swedish Heart-Lung Foundation, the Swedish Order of St. John, Friends of Karolinska Institute, and private donors, as well as from an unrestricted sponsorship from Boehringer-Ingelheim. SITS has previously received grants from the European Union Framework 7, the European Union Public Health Authority and Ferrer International. SITS is currently conducting studies supported by Boehringer-Ingelheim and EVER Pharma, as well as in collaboration with Karolinska Institute, supported by Stryker, Covidien and Phenox. N Ahmed is supported by grants provided by the Stockholm County Council and the Swedish Heart-Lung Foundation. No funding sources had part in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.",
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T1 - Intravenous Thrombolysis for Ischemic Stroke Patients on Dual Antiplatelets

AU - Tsivgoulis, Georgios

AU - Katsanos, Aristeidis H.

AU - Mavridis, Dimitris

AU - Gdovinova, Zuzana

AU - Karlinski, Michal

AU - Macleod, Mary Joan

AU - Strbian, Daniel

AU - Ahmed , Niaz

N1 - We thank all SITS-ISTR investigators and their centers for their participation. We also pass on our thanks to all patients who participated in SITS-ISTR. The current SITS registry is developed, maintained and upgraded by Zitelab, Copenhagen, Denmark, in close collaboration with SITS. SITS (Safe Implementation of Treatment in Stroke) is financed directly and indirectly by grants from Karolinska Institute, Stockholm County Council, the Swedish Heart-Lung Foundation, the Swedish Order of St. John, Friends of Karolinska Institute, and private donors, as well as from an unrestricted sponsorship from Boehringer-Ingelheim. SITS has previously received grants from the European Union Framework 7, the European Union Public Health Authority and Ferrer International. SITS is currently conducting studies supported by Boehringer-Ingelheim and EVER Pharma, as well as in collaboration with Karolinska Institute, supported by Stryker, Covidien and Phenox. N Ahmed is supported by grants provided by the Stockholm County Council and the Swedish Heart-Lung Foundation. No funding sources had part in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

PY - 2018/7

Y1 - 2018/7

N2 - ObjectiveWe assessed the outcomes of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients on dual antiplatelet therapy prior to stroke onset.MethodsWe analyzed prospectively collected data from the SITS International Stroke Thrombolysis Register (SITS‐ISTR) on consecutive IVT‐treated AIS patients during a seven‐year period (2010‐2017). In propensity‐score matched groups of patients with dual antiplatelet pretreatment and no antiplatelet pretreatment we compared: 1) SICH, according to SITS‐MOST, ECASS II and NINDS definitions, 2) 3‐month mortality, 3) 3‐month favorable functional outcome (FFO; mRS‐scores:0‐1), 4) 3‐month functional independence (FI; mRS‐scores:0‐2) and 5) distribution of the 3‐month mRS‐scores. Dual antiplatelet pretreatment was defined as all possible combinations among aspirin, clopidogrel, dipyridamole or any other antiplatelet.ResultsPropensity‐score matching resulted in two groups of 1043 patients each, balanced for all baseline characteristics. In the propensity‐score matched analysis the two groups had comparable (p>0.017 using Bonferroni correction for multiple comparisons) SICH rates according to SITS‐MOST (2.9% vs. 1.5%; 95%CI:‐0.03,‐0.01), ECASS II (5.2% vs. 4.4%; 95%CI:‐0.03,0.01) and NINDS (7.7% vs. 6.6%; 95%CI:‐0.03,0.01) definitions. No differences in the 3‐month mortality (17.9% vs. 16.6%; 95%CI:‐0.05,0.02), FFO (45.6% vs. 46.0%; 95%CI:‐0.04,0.05), FI rates (59.2% vs. 60.7%; 95%CI:‐0.03,0.06) or the distribution in 3‐month mRS‐scores [2 (1‐4) vs. 2 (0‐4); 95%CI:‐0.29,0.09] were documented between the two groups.InterpretationGiven that patients on dual antiplatelet pretreatment have similar SICH, 3‐month mortality rates and functional outcomes compared to patients with no antiplatelet pretreatment, dual antiplatelet pretreatment history should not be used as a reason to withhold IVT in otherwise eligible AIS patients.

AB - ObjectiveWe assessed the outcomes of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients on dual antiplatelet therapy prior to stroke onset.MethodsWe analyzed prospectively collected data from the SITS International Stroke Thrombolysis Register (SITS‐ISTR) on consecutive IVT‐treated AIS patients during a seven‐year period (2010‐2017). In propensity‐score matched groups of patients with dual antiplatelet pretreatment and no antiplatelet pretreatment we compared: 1) SICH, according to SITS‐MOST, ECASS II and NINDS definitions, 2) 3‐month mortality, 3) 3‐month favorable functional outcome (FFO; mRS‐scores:0‐1), 4) 3‐month functional independence (FI; mRS‐scores:0‐2) and 5) distribution of the 3‐month mRS‐scores. Dual antiplatelet pretreatment was defined as all possible combinations among aspirin, clopidogrel, dipyridamole or any other antiplatelet.ResultsPropensity‐score matching resulted in two groups of 1043 patients each, balanced for all baseline characteristics. In the propensity‐score matched analysis the two groups had comparable (p>0.017 using Bonferroni correction for multiple comparisons) SICH rates according to SITS‐MOST (2.9% vs. 1.5%; 95%CI:‐0.03,‐0.01), ECASS II (5.2% vs. 4.4%; 95%CI:‐0.03,0.01) and NINDS (7.7% vs. 6.6%; 95%CI:‐0.03,0.01) definitions. No differences in the 3‐month mortality (17.9% vs. 16.6%; 95%CI:‐0.05,0.02), FFO (45.6% vs. 46.0%; 95%CI:‐0.04,0.05), FI rates (59.2% vs. 60.7%; 95%CI:‐0.03,0.06) or the distribution in 3‐month mRS‐scores [2 (1‐4) vs. 2 (0‐4); 95%CI:‐0.29,0.09] were documented between the two groups.InterpretationGiven that patients on dual antiplatelet pretreatment have similar SICH, 3‐month mortality rates and functional outcomes compared to patients with no antiplatelet pretreatment, dual antiplatelet pretreatment history should not be used as a reason to withhold IVT in otherwise eligible AIS patients.

KW - acute ischemic stroke

KW - dual antiplatelet therapy

KW - mortality

KW - functional outcome

KW - intracranial hemorrhage

U2 - 10.1002/ana.25269

DO - 10.1002/ana.25269

M3 - Article

VL - 84

SP - 89

EP - 97

JO - Annals of Neurology

JF - Annals of Neurology

SN - 0364-5134

IS - 1

ER -