Acute ischemic stroke: ticagrelor-aspirin tops aspirin alone

  • Johnston SC & al.
  • N Engl J Med
  • 16/07/2020

  • Susan London
  • Clinical Essentials
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Takeaway

  • Among patients with mild to moderate ischemic stroke or transient ischemic attack (TIA), adding ticagrelor to aspirin reduces risk for recurrent stroke or death with a trade-off of increased severe bleeding.

Why this matters

  • Editorial notes other data supporting the combination of aspirin plus clopidogrel and recommends aspirin as a "simple treatment" for all patients after TIA, barring contraindications. 

Key results

  • 30-day risk for recurrent stroke (any type) or death:
    • 5.5% with ticagrelor-aspirin vs 6.6% with aspirin alone.
    • HR, 0.83 (95% CI, 0.71-0.96).
  • Ischemic stroke:
    • 5.0% with ticagrelor-aspirin vs 6.3% with aspirin alone.
    • HR, 0.79 (95% CI, 0.68-0.93).
  • About 24% of patients in both groups became disabled (modified Rankin scale score >1; P=.61).
  • Severe bleeding:
    • 0.5% with ticagrelor-aspirin vs 0.1% with aspirin alone.
    • HR, 3.99 (95% CI, 1.74-9.14).

Study design

  • International randomized controlled trial with 11,016 patients who had mild to moderate acute noncardioembolic ischemic stroke or TIA not undergoing thrombolysis or thrombectomy.
  • Participants were randomly assigned within 24 hours after symptom onset to 30-day regimen of either ticagrelor (180 mg loading dose, then 90 mg twice daily) plus aspirin (300-325 mg on first day, then 75-100 mg daily) or matching placebo plus aspirin.
  • Main outcome: composite of stroke or death within 30 days.
  • Funding: AstraZeneca.

Limitations

  • Different patient populations, outcome definitions prevent cross-trial comparisons.
  • Unknown generalizability.