J Korean Med Sci.  2023 Sep;38(38):e294. 10.3346/jkms.2023.38.e294.

Multiple Antiplatelet Therapy in Ischemic Stroke Already on Antiplatelet Agents Based on the Linked Big Data for Stroke

• Kim TJ
• Lee JS
• Yoon JS
• Park SH
• Oh MS
• Jung KH
• Yu KH
• Lee BC
• Ko SB
• Yoon BW

• KMID: 2546217
• DOI: http://doi.org/10.3346/jkms.2023.38.e294

Abstract

Background
Optimal antiplatelet strategy for patients with ischemic stroke who were already on single antiplatelet therapy (SAPT) remains to be elucidated. This study aimed to evaluate the effect of different antiplatelet regimens on vascular and safety outcomes at 1 year after non-cardioembolic stroke in patients previously on SAPT.
Methods
We identified 9,284 patients with acute non-cardioembolic ischemic stroke that occurred on SAPT using linked data. Patients were categorized into three groups according to antiplatelet strategy at discharge: 1) SAPT; 2) dual antiplatelet therapy (DAPT); and 3) triple antiplatelet therapy (TAPT). One-year outcomes included recurrent ischemic stroke, composite outcomes (recurrent ischemic stroke, myocardial infarction, intracerebral hemorrhage, and death), and major bleeding.
Results
Of 9,284 patients, 5,565 (59.9%) maintained SAPT, 3,638 (39.2%) were treated with DAPT, and 81 (0.9%) were treated with TAPT. Multiple antiplatelet therapy did not reduce the risks of 1-year recurrent stroke (DAPT, hazard ratio [HR], 1.08, 95% confidence interval [CI], 0.92–1.27, P = 0.339; TAPT, HR, 0.71, 95% CI, 0.27–1.91, P = 0.500) and 1-year composite outcome (DAPT, HR, 1.09, 95% CI, 0.68–1.97, P = 0.592; TAPT, HR, 1.46, 95% CI, 0.68–1.97, P = 0.592). However, the TAPT groups showed an increased risk of major bleeding complications (DAPT, HR, 1.23, 95% CI, 0.89–1.71, P = 0.208; TAPT, HR, 4.65, 95% CI, 2.01–10.74, P < 0.001).
Conclusion
Additional use of antiplatelet agents in patients with non-cardioembolic ischemic stroke who were already on SAPT did not reduce the 1-year incidence of vascular outcomes, although it increased the risk of bleeding complications.

Keyword

Multiple Antiplatelet Therapy; Non-Cardioembolic Stroke; Vascular Outcome; Bleeding Risk

Figure

• 

  Fig. 1 Flow diagram of included study patients.MI = myocardial infarction, ICH = intracerebral hemorrhage, GI = gastrointestinal, SAPT = single antiplatelet therapy, DAPT = dual antiplatelet therapy, TAPT = triple antiplatelet therapy.

• 

  Fig. 2 Kaplan-Meier analysis of primary outcome and secondary outcome in the total patients. (A) Cumulative incidence of the composite outcome. (B) Cumulative incidence of the ischemic stroke. (C) Cumulative incidence of the myocardial infarction. (D) Cumulative incidence of the intracerebral hemorrhage. (E) Cumulative incidence of GI bleeding. (F) Cumulative incidence of major bleeding. (G) Cumulative incidence of all-cause death.GI = gastrointestinal, SAPT = single antiplatelet therapy, DAPT = dual antiplatelet therapy, TAPT = triple antiplatelet therapy.

• 

  Fig. 3 HR for primary outcome and secondary outcome in the total patients. DAPT and TAPT did not reduce the 1-year incidence of composite outcome, recurrent stroke, myocardial infarction, and all-cause death. Instead, DAPT and TAPT were associated with a higher rate of bleeding events than maintaining SAPT in patients with acute non-cardioembolic ischemic stroke who were already on SAPT.SAPT = single antiplatelet therapy, DAPT = dual antiplatelet therapy, TAPT = triple antiplatelet therapy, GI = gastrointestinal, HR = hazard ratio, CI = confidence interval.

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