Rewards may outweigh risks for stroke patients on tPA, antiplatelet therapy

November 18, 2015 – Stroke patients on antiplatelet therapy who are treated with intravenous tPA have a slightly higher risk of bleeding, but better overall outcomes.

Stroke patients who receive intravenous tissue plasminogen activator (tPA) as well as antiplatelet therapy are at increased risk of bleeding, but have better functional outcomes than tPA patients who do not receive antiplatelet therapy.

New research by DCRI faculty members published online this month in the journal JAMA Neurology suggests that the overall benefits of antiplatelet therapy may outweigh the risks in for such patients.

ying-xian research has established that tPA therapy improves outcomes for stroke patients. However, tPA also carries the risk for symptomatic intracranial hemorrhage (sICH), a serious complication of thrombolysis for acute ischemic stroke. Approximately 40 percent of patients receive antiplatelet therapy before their stroke, and concomitant tPA treatment increase the risk of bleeding for these patients.

To assess the relative risk for patients with intravenous tPA who also received antiplatelet therapy, the DCRI’s Ying Xian, MD, PhD, and his colleagues analyzed patient data from the American Heart Association and American Stroke Association Get With the Guidelines–Stroke (GWTG-Stroke) program. They identified 85,072 adult patients with ischemic stroke who received intravenous tPA at 1,545 U.S. hospitals between 2009 and mid-2015.

Of these patients, 38,844 (45.7 percent) were using antiplatelet therapy before admission and 46,228 (54.3 percent) were not. Patients who received antiplatelet therapy before admission tended to be older, have more cardiovascular risk factors, and were more likely to receive medications to lower cholesterol, blood pressure, or glucose levels. However, they were less likely to receive anticoagulants before admission.

Patients who received antiplatelet therapy had a higher unadjusted rate of sICH than those who did not (5.0 percent versus 3.7 percent). After risk adjustment, patients who were previously on antiplatelet therapy still had higher odds of sICH compared to those who did not, although the overall risk was small.

The risk for in-hospital mortality was similar between those who were and were not receiving antiplatelet therapy after adjustment (8.0 percent versus 6.6 percent). However, patients receiving antiplatelet therapy were more likely to achieve independent ambulation (42.1 percent versus 46.6 percent) and had better functional outcomes at discharge (24.1 percent versus 27.8 percent).

These results, the researchers concluded, demonstrate that the risk for sICH among patients with stroke who receive antiplatelet therapy before the stroke and are treated with intravenous tPA is relatively low and should be weighed against the potential benefits in terms of improved functional outcomes.

In addition to Xian, the study’s other Duke authors included Maria Grau-Sepulveda, MD, MPH; Adrian F. Hernandez, MD, MHS; Laine Thomas, PhD; Laura Webb, MS; Janet Prvu Bettger, ScD; Daniel T. Laskowitz, MD, MHS; and Eric D. Peterson, MD, MPH.