Aspirin Plus Ticagrelor vs Aspirin Alone: Which Is Better in Reducing Disabling Recurrent Stroke?

Adding ticagralor to aspirin appears to be superior to aspirin alone in the prevention of disabling stroke or mortality at 30 days, and reduces the overall disability burden of ischemic stroke recurrence among patients with transient ischemic attack (TIA) and minor ischemic stroke, according to new findings.

Investigators arrived at their conclusion after performing the Acute Stroke or Transient Ischemic Attack Treated With Ticagrelor and Aspirin for Prevention of Stroke and Death randomized clinical trial (N = 11,016). All patients included in the study had a noncardioembolic, nonsevere ischemic stroke or high-risk TIA, and most (n = 10,083) had a modified Rankin Scale score (mRS) that had been documented at 30 days.

The trial was performed between January 22, 2018, and December 13, 2019, and follow-up lasted 30 days. All patients were administered 300 mg to 325 mg aspirin on day 1, and 75 mg to 100 mg each day from day 2 through day 30. Patients also received either ticagrelor (administered in a 180-mg loading dose on the first day and in twice-daily, 90-mg doses from days 2 through 30) or placebo within 24 hours of the onset of symptoms.

Primary outcomes were defined as time to the occurrence of disabling stroke, including progression of initial event or a new stroke, or mortality within 30 days based on mRS measurement at day 30. The investigators defined disabling stroke as an mRS above 1.

The results of the trial indicated that, at 30 days, 221 (4.0%) of 5511 patients randomly assigned to ticagrelor had experienced a primary endpoint with an mRS greater than 1 compared with 260 (4.7%) of 5478 patients randomly assigned to placebo (hazard ratio [HR] 0.83). Seventy (1.3%) of 5511 patients in the ticagrelor group who had an mRS of 0 or 1 at 30 days had experienced a primary endpoint compared with 87 (1.6%) of 5478 placebo-treated patients in the same mRS range.

Among patients with recurrent stroke, an ordinal analysis of mRS indicated that disability burden after recurrent ischemic stroke had shifted in favor of ticagrelor (odds ratio 0.77). A National Institutes of Health Stroke Scale score of 4 to 5 at baseline, Asian race/ethnicity, ipsilateral stenosis of at least 30%, and higher systolic blood pressure were associated with disability, whereas ticagrelor use was associated with reduced disability.

—Christina Vogt

Reference:
Amarenco P, Denison H, Evans SR, et al. Ticagrelor added to aspirin in acute ischemic stroke or transient ischemic attack in prevention of disabling stroke: A randomized clinical trial. JAMA Neurol. Published online November 7, 2020. doi:10.1001/jamaneurol.2020.4396