Aspirin ticagrelor combo reduces stroke, death risk in TIA patients: NEJM

USA: Ticagrelor-aspirin versus aspirin alone reduced the risk of the composite of stroke or death within 30 days in patients with mild-to-moderate acute noncardioembolic ischemic stroke or TIA, finds a recent study. The study, published in the New England Journal of Medicine, further found that the incidence of disability did not differ significantly between the two groups and severe bleeding was more frequent with ticagrelor.

Previous studies have evaluated the use of clopidogrel and aspirin for stroke prevention after a transient ischemic attack (TIA) or ischemic stroke. Ticagrelor was not found to be better than aspirin in preventing death or vascular events after stroke or TIA. The effect of the combination of ticagrelor and aspirin has not been studied well.

S. Claiborne Johnston, the University of Texas at Austin, Austin, Texas, and colleagues assessed the safety and efficacy of dual antiplatelet therapy (DAPT) with aspirin and ticagrelor compared with aspirin alone among patients with acute noncardioembolic ischemic stroke.

For the purpose, they conducted a randomized, placebo-controlled, double-blind trial. It involved patients who had a mild-to-moderate acute noncardioembolic ischemic stroke, with a National Institutes of Health Stroke Scale (NIHSS) score of 5 or less (range, 0 to 42, with higher scores indicating more severe stroke), or TIA and who were not undergoing thrombolysis or thrombectomy. They were assigned in the ratio 1:1 to receive a 30-day regimen of either ticagrelor (180-mg loading dose followed by 90 mg twice daily) plus aspirin (300 to 325 mg on the first day followed by 75 to 100 mg daily) or matching placebo plus aspirin, within 24 hours after symptom onset.

The primary outcome was a composite of stroke or death within 30 days. Secondary outcomes were the first subsequent ischemic stroke and the incidence of disability within 30 days. The primary safety outcome was severe bleeding.

A total of 11,016 patients underwent randomization (5523 in the ticagrelor–aspirin group and 5493 in the aspirin group). 

"Among patients with a mild-to-moderate acute noncardioembolic ischemic stroke (NIHSS score ≤5) or TIA who were not undergoing intravenous or endovascular thrombolysis, the risk of the composite of stroke or death within 30 days was lower with ticagrelor–aspirin than with aspirin alone, but the incidence of disability did not differ significantly between the two groups. Severe bleeding was more frequent with ticagrelor," concluded the authors.

The study, "Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA," is published in the journal NEJM.

DOI: 10.1056/NEJMoa1916870