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Transient ischemic attack (TIA) or mild ischemic stroke patients with ipsilateral intracranial and extracranial atherosclerotic stenosis (hereinafter referred to as "ipsilateral stenosis") are at high risk of recurring vascular events.
Recently, an exploratory analysis of the THALES study published in the journal Stroke showed that patients with ipsilateral stenosis have a higher absolute risk of stroke or death at 30 days, which is about twice as high as that of patients without ipsilateral stenosis.
Grilor combined with aspirin treatment can significantly reduce the relative risk of this composite endpoint by 27%.
THALES study exploratory analysis: significantly reduced the 30-day risk of stroke or death in patients with ipsilateral stenosis by 27%.
The THALES study is an international multi-center, randomized, double-blind controlled study that included 11 016 non-cardiogenic, non-severe deficiency cases.
Patients with blood stroke or high-risk TIA.
Patients were randomly divided into groups within 24 hours of onset of symptoms.
The experimental group received ticagrelor (first dose 180 mg, 90 mg bid maintenance) combined with aspirin (first dose 300-325 mg, 75-100 mg qd maintenance) for 30 days ; The control group received placebo combined with aspirin (dose same as before) for 30 days.
The primary endpoint of the study was stroke and death within 30 days.
A total of 2351 patients (21.
3%) in the study had ipsilateral stenosis (defined as intracranial or extracranial ipsilateral stenosis ≥30%, with or without aortic arch plaque thickness ≥4 mm).
The analysis found that among patients with ipsilateral stenosis, the 30-day rate of stroke or death in the ticagrelor group was 8.
1% (92/1136) and 10.
9% (132/1215) in the placebo group; ticagrelor Compared with the placebo group, the 30-day risk of stroke or death in the Luo group was significantly reduced by 27% (HR=0.
73, 95%CI: 0.
56-0.
96, P=0.
023); the number of patients who needed treatment to avoid 1 stroke or death (NNT) Is 34. In patients without ipsilateral stenosis, the 30-day stroke or death rates in the ticagrelor group and placebo group were 4.
8% (211/4387) and 5.
4% (230/4278) (HR=0.
89, 95) %CI: 0.
74–1.
08; P=0.
23, Pinteraction=0.
245).
Figure 1 Kaplan-Meier curve of the primary endpoint in patients with or without ipsilateral stenosis.
In addition, the risk of ischemic stroke in the ticagrelor group was significantly lower than that in the placebo group by 28%; the incidence of ischemic stroke in both groups They were 7.
7% (87 cases) and 10.
5% (127 cases) (HR=0.
72, 95CI: 0.
55-0.
95, P=0.
020).
Subgroup analysis showed that, except for the subgroup of patients weighing less than 70 kg, the benefit of ticagrelor in reducing the 30-day risk of stroke or death was observed in all other subgroups (Figure 2).
Moreover, it is particularly worth noting that the absolute benefit of Asian patients receiving ticagrelor treatment is greater (10.
3% vs 16.
2%, HR=0.
61, 95%CI: 0.
43-0.
87, Pinteraction=0.
09, NNT=17) .
Figure 2 Subgroup analysis of patients with ipsilateral stenosis.
In terms of safety, among patients with ipsilateral stenosis, the incidence of severe bleeding in the ticagrelor group and placebo group was 0.
4% (4 cases) and 0.
2% (3).
Example), there is no significant difference between the groups (P=NS).
However, among patients without ipsilateral stenosis, the incidence of severe bleeding was higher in the ticagrelor group, 0.
5% (24 cases) and 0.
1% (4 cases) in the two groups (HR=5.
87, 95%CI: 2.
04) -16.
9, P=0.
001).
Experts comment on the Department of Neurology, Peking Union Medical College Hospital, Xu Weihai, focusing on high-risk groups.
Ticagrelor brings greater benefits.
40% of ischemic stroke patients have ipsilateral stenosis, and their risk of recurrence is much higher than that of patients with other subtypes.
The exploratory analysis of the THALES study also found that the 30-day risk of stroke or death in patients with ipsilateral stenosis was about twice that of patients without ipsilateral stenosis.
Therefore, early and effective intervention for such patients is essential.
In fact, for patients with large atherosclerotic ischemic stroke, the prevention of stroke through antiplatelet therapy is mainly to avoid the rupture of atherosclerotic plaque, which leads to thrombosis.
As a potent and fast-acting P2Y12 receptor inhibitor, ticagrelor’s clinical benefits have been demonstrated in a number of studies, including THALES, SOCRATES, PRINCE, and development in patients with coronary artery disease.
Test and so on.
Especially for patients with low risk of bleeding, ticagrelor combined with aspirin is the preferred treatment for atherosclerotic diseases.
In the SOCRATES study, compared with aspirin, ticagrelor significantly reduced the relative risk of stroke or cardiovascular events in patients with ipsilateral stenosis of TIA or mild ischemic stroke by 32%.
It has been shown that ticagrelor is here.
Applicable prospects in the category of patients.
The THALES study published in the New England Journal of Medicine in July 2020 showed that compared with aspirin alone, ticagrelor combined with aspirin can significantly reduce the 30-day risk of stroke or death in patients with TIA or mild ischemic stroke by 17% , The number of patients requiring treatment (NNT) to avoid 1 stroke or death is 92.
This exploratory analysis of the THALES study included a total of 2351 patients with ipsilateral stenosis ≥30% with or without aortic arch plaque thickness ≥4 mm, and found that ticagrelor combined with aspirin significantly reduced stroke or The risk of death is 27%, and the NNT is only 34.
Combining the above research and analysis results, we can find that patients with ischemic stroke with ipsilateral stenosis may benefit more from ticagrelor combined with aspirin treatment, which will help guide us in clinical practice.
Control the benefiting population of dual antiplatelet therapy.
Bleeding risk is also the focus of attention in antiplatelet therapy.
The safety results of this THALES atherosclerosis subgroup analysis showed that ticagrelor combined with aspirin did not increase the risk of serious bleeding, and one patient who needed treatment for bleeding occurred The number (NNH) is 951, which is higher than the total population of 263.
However, due to the small number of safety end-point events, we should also interpret it with caution.
In addition, in patients with and without ipsilateral stenosis, the difference in bleeding risk between the ticagrelor group and the placebo group may be due to the higher incidence of small vessel disease in patients without ipsilateral stenosis, which has caused a large Part of the bleeding event.
In the MATCH, PRoFESS, and SPS-3 trials, dual antiplatelet therapy significantly increased the risk of severe bleeding compared with monotherapy.
The proportions of patients with small vessel disease in these three trials were relatively high, 53%, respectively.
52% and 100%.
Therefore, when choosing a patient's antiplatelet treatment plan, it is necessary to combine the specific conditions of the patient and comprehensively weigh the proportions to maximize the benefits of the patient while ensuring safety.
At present, after arriving at the stroke center, patients will undergo CT angiography, magnetic resonance imaging (MRI) or ultrasound imaging of the intracranial and extracranial arteries, so it is easy to identify potential intervention groups in clinical practice.
In combination with this analysis, in the subgroup of patients with intracranial or extracranial ipsilateral stenosis ≥30% with or without aortic arch plaque thickness ≥4 mm, the NNT of ticagrelor combined with aspirin was 34, and the NNH was 951.
Therefore, it may be appropriate for this subgroup to give ticagrelor combined with aspirin treatment for 30 days after the onset of stroke.
The publication of the results of THALES and its subgroup studies provides strong evidence for ticagrelor combined with aspirin dual antiplatelet therapy for patients with TIA and mild ischemic stroke, which is expected to rewrite clinical practice.
Typesetting: Li Hui Editor: Huang Lingling Review: Wang Lina For more content, please click: Hu Jianli: Fatigue is the most important subjective feeling for cancer patients.
The "Physician Daily" award-winning survey is waiting for you to participate in the "Physician Daily" submission Public email: yishibao2017@163.
com [Note] Some pictures are from the Internet and WeChat Moments Dear image authors, hello, the Physician Daily is ready for you For the contribution fee, please contact the editor on duty: 010-58302828-6808.
Currently 1130000+ doctors have been paying attention to join us
Recently, an exploratory analysis of the THALES study published in the journal Stroke showed that patients with ipsilateral stenosis have a higher absolute risk of stroke or death at 30 days, which is about twice as high as that of patients without ipsilateral stenosis.
Grilor combined with aspirin treatment can significantly reduce the relative risk of this composite endpoint by 27%.
THALES study exploratory analysis: significantly reduced the 30-day risk of stroke or death in patients with ipsilateral stenosis by 27%.
The THALES study is an international multi-center, randomized, double-blind controlled study that included 11 016 non-cardiogenic, non-severe deficiency cases.
Patients with blood stroke or high-risk TIA.
Patients were randomly divided into groups within 24 hours of onset of symptoms.
The experimental group received ticagrelor (first dose 180 mg, 90 mg bid maintenance) combined with aspirin (first dose 300-325 mg, 75-100 mg qd maintenance) for 30 days ; The control group received placebo combined with aspirin (dose same as before) for 30 days.
The primary endpoint of the study was stroke and death within 30 days.
A total of 2351 patients (21.
3%) in the study had ipsilateral stenosis (defined as intracranial or extracranial ipsilateral stenosis ≥30%, with or without aortic arch plaque thickness ≥4 mm).
The analysis found that among patients with ipsilateral stenosis, the 30-day rate of stroke or death in the ticagrelor group was 8.
1% (92/1136) and 10.
9% (132/1215) in the placebo group; ticagrelor Compared with the placebo group, the 30-day risk of stroke or death in the Luo group was significantly reduced by 27% (HR=0.
73, 95%CI: 0.
56-0.
96, P=0.
023); the number of patients who needed treatment to avoid 1 stroke or death (NNT) Is 34. In patients without ipsilateral stenosis, the 30-day stroke or death rates in the ticagrelor group and placebo group were 4.
8% (211/4387) and 5.
4% (230/4278) (HR=0.
89, 95) %CI: 0.
74–1.
08; P=0.
23, Pinteraction=0.
245).
Figure 1 Kaplan-Meier curve of the primary endpoint in patients with or without ipsilateral stenosis.
In addition, the risk of ischemic stroke in the ticagrelor group was significantly lower than that in the placebo group by 28%; the incidence of ischemic stroke in both groups They were 7.
7% (87 cases) and 10.
5% (127 cases) (HR=0.
72, 95CI: 0.
55-0.
95, P=0.
020).
Subgroup analysis showed that, except for the subgroup of patients weighing less than 70 kg, the benefit of ticagrelor in reducing the 30-day risk of stroke or death was observed in all other subgroups (Figure 2).
Moreover, it is particularly worth noting that the absolute benefit of Asian patients receiving ticagrelor treatment is greater (10.
3% vs 16.
2%, HR=0.
61, 95%CI: 0.
43-0.
87, Pinteraction=0.
09, NNT=17) .
Figure 2 Subgroup analysis of patients with ipsilateral stenosis.
In terms of safety, among patients with ipsilateral stenosis, the incidence of severe bleeding in the ticagrelor group and placebo group was 0.
4% (4 cases) and 0.
2% (3).
Example), there is no significant difference between the groups (P=NS).
However, among patients without ipsilateral stenosis, the incidence of severe bleeding was higher in the ticagrelor group, 0.
5% (24 cases) and 0.
1% (4 cases) in the two groups (HR=5.
87, 95%CI: 2.
04) -16.
9, P=0.
001).
Experts comment on the Department of Neurology, Peking Union Medical College Hospital, Xu Weihai, focusing on high-risk groups.
Ticagrelor brings greater benefits.
40% of ischemic stroke patients have ipsilateral stenosis, and their risk of recurrence is much higher than that of patients with other subtypes.
The exploratory analysis of the THALES study also found that the 30-day risk of stroke or death in patients with ipsilateral stenosis was about twice that of patients without ipsilateral stenosis.
Therefore, early and effective intervention for such patients is essential.
In fact, for patients with large atherosclerotic ischemic stroke, the prevention of stroke through antiplatelet therapy is mainly to avoid the rupture of atherosclerotic plaque, which leads to thrombosis.
As a potent and fast-acting P2Y12 receptor inhibitor, ticagrelor’s clinical benefits have been demonstrated in a number of studies, including THALES, SOCRATES, PRINCE, and development in patients with coronary artery disease.
Test and so on.
Especially for patients with low risk of bleeding, ticagrelor combined with aspirin is the preferred treatment for atherosclerotic diseases.
In the SOCRATES study, compared with aspirin, ticagrelor significantly reduced the relative risk of stroke or cardiovascular events in patients with ipsilateral stenosis of TIA or mild ischemic stroke by 32%.
It has been shown that ticagrelor is here.
Applicable prospects in the category of patients.
The THALES study published in the New England Journal of Medicine in July 2020 showed that compared with aspirin alone, ticagrelor combined with aspirin can significantly reduce the 30-day risk of stroke or death in patients with TIA or mild ischemic stroke by 17% , The number of patients requiring treatment (NNT) to avoid 1 stroke or death is 92.
This exploratory analysis of the THALES study included a total of 2351 patients with ipsilateral stenosis ≥30% with or without aortic arch plaque thickness ≥4 mm, and found that ticagrelor combined with aspirin significantly reduced stroke or The risk of death is 27%, and the NNT is only 34.
Combining the above research and analysis results, we can find that patients with ischemic stroke with ipsilateral stenosis may benefit more from ticagrelor combined with aspirin treatment, which will help guide us in clinical practice.
Control the benefiting population of dual antiplatelet therapy.
Bleeding risk is also the focus of attention in antiplatelet therapy.
The safety results of this THALES atherosclerosis subgroup analysis showed that ticagrelor combined with aspirin did not increase the risk of serious bleeding, and one patient who needed treatment for bleeding occurred The number (NNH) is 951, which is higher than the total population of 263.
However, due to the small number of safety end-point events, we should also interpret it with caution.
In addition, in patients with and without ipsilateral stenosis, the difference in bleeding risk between the ticagrelor group and the placebo group may be due to the higher incidence of small vessel disease in patients without ipsilateral stenosis, which has caused a large Part of the bleeding event.
In the MATCH, PRoFESS, and SPS-3 trials, dual antiplatelet therapy significantly increased the risk of severe bleeding compared with monotherapy.
The proportions of patients with small vessel disease in these three trials were relatively high, 53%, respectively.
52% and 100%.
Therefore, when choosing a patient's antiplatelet treatment plan, it is necessary to combine the specific conditions of the patient and comprehensively weigh the proportions to maximize the benefits of the patient while ensuring safety.
At present, after arriving at the stroke center, patients will undergo CT angiography, magnetic resonance imaging (MRI) or ultrasound imaging of the intracranial and extracranial arteries, so it is easy to identify potential intervention groups in clinical practice.
In combination with this analysis, in the subgroup of patients with intracranial or extracranial ipsilateral stenosis ≥30% with or without aortic arch plaque thickness ≥4 mm, the NNT of ticagrelor combined with aspirin was 34, and the NNH was 951.
Therefore, it may be appropriate for this subgroup to give ticagrelor combined with aspirin treatment for 30 days after the onset of stroke.
The publication of the results of THALES and its subgroup studies provides strong evidence for ticagrelor combined with aspirin dual antiplatelet therapy for patients with TIA and mild ischemic stroke, which is expected to rewrite clinical practice.
Typesetting: Li Hui Editor: Huang Lingling Review: Wang Lina For more content, please click: Hu Jianli: Fatigue is the most important subjective feeling for cancer patients.
The "Physician Daily" award-winning survey is waiting for you to participate in the "Physician Daily" submission Public email: yishibao2017@163.
com [Note] Some pictures are from the Internet and WeChat Moments Dear image authors, hello, the Physician Daily is ready for you For the contribution fee, please contact the editor on duty: 010-58302828-6808.
Currently 1130000+ doctors have been paying attention to join us
