Prestroke Antiplatelet Therapy Linked With Symptomatic Intracerebral Hemorrhage After Thrombolysis

Prestroke single and dual antiplatelet therapy are associated with an increased risk of symptomatic intracerebral hemorrhage after treatment with intravenous alteplase for acute ischemic stroke, according to study findings published in JAMA Neurology.

The cohort study included 321,819 patients hospitalized with acute ischemic stroke and treated with intravenous alteplase between 2013 and 2021 from the American Heart Association and American Stroke Association Get With The Guidelines–Stroke registry. Researchers used propensity score matching analysis to determine the risk of symptomatic intracerebral hemorrhage in patients taking dual antiplatelet therapy.

Symptomatic intracerebral hemorrhage rates were 2.9% in patients treated with no antiplatelet therapy, 3.8% in patients treated with single antiplatelet therapy, and 4.1% in patients treated with dual antiplatelet therapy, the study found.

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After propensity score subclassification, both single and dual antiplatelet exposure were associated with an elevated symptomatic intracerebral hemorrhage risk. Odds ratios for symptomatic intracerebral hemorrhage were 1.13 for single antiplatelet therapy and 1.28 for dual antiplatelet therapy, researchers reported.

The odds of a discharge modified Rankin scale score of 2 or less, signaling a good functional outcome, were also lower with prestroke antiplatelet medications. Odds ratios for a score of 2 or less were 0.92 with single antiplatelet therapy and 0.94 with dual antiplatelet therapy.

Rates of symptomatic intracerebral hemorrhage or functional outcomes in patients treated with dual antiplatelet therapy did not differ significantly between aspirin-clopidogrel and aspirin-ticagrelor, subgroup analysis showed.

“Prestroke dual antiplatelet therapy was associated with a significantly elevated risk of symptomatic intracerebral hemorrhage among patients with ischemic stroke who were treated with thrombolysis; however, the absolute increase in risk was small,” researchers wrote. “Patients exposed to antiplatelet medications did not have excess symptomatic intracerebral hemorrhage compared with landmark trials, which demonstrated overall clinical benefit of thrombolysis therapy for acute ischemic stroke.”

Reference

Peng TJ, Schwamm LH, Fonarow GC, et al. Contemporary prestroke dual antiplatelet use and symptomatic intracerebral hemorrhage risk after thrombolysis. JAMA Neurol. Published online May 20, 2024. doi:10.1001/jamaneurol.2024.1312