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Favourable clinical outcomes, lower sICH with low-dose alteplase in patients with prior antiplatelet therapy

Audrey Abella
17 Aug 2017

The use of low-dose intravenous (IV) alteplase may be associated with more favourable clinical outcomes and lower risk of symptomatic intracerebral haemorrhage (sICH) in thrombolysis-treated acute ischaemic stroke patients who previously received antiplatelet therapy (APT) compared with the standard dose, according to the ENCHANTED* trial.

This multicentre, prospective, blinded-end point trial included 3,285 patients (mean age 66.6 years, 38 percent women). The 752 patients who reported prior APT use were randomized to receive low-dose (0.6 mg/kg, n=407) or standard-dose (0.9 mg/kg, n=345) IV alteplase within 4.5 hours of symptom onset.

Although not significant, low-dose alteplase resulted in a more favourable 90-day clinical outcome than standard-dose alteplase in patients with APT history vs those without prior APT based on mRS (modified Rankin Scale) scores 2–6 (odds ratio [OR], 0.84 vs OR, 1.16; p-trend=0.053), mRS scores 3–6 (OR, 0.80 vs OR, 1.10; p-trend=0.065), or ordinal mRS shift (OR, 0.76 vs OR, 1.07; p interaction=0.023). [Stroke 2017;48:1877-1883]

Based on the SITS-MOST** criteria, prior APT use was associated with an increased sICH risk (adjusted OR, 1.82, 95 percent CI, 1.00–3.30; p=0.051), which decreased in patients given low-dose vs standard-dose alteplase (OR, 0.38, 95 percent CI, 0.14–1.02).

“Patients on prior APT … are at significantly higher risk of sICH and poor outcome compared with other patients who receive alteplase,” said the researchers. “[T]his may be considered an important treatment option in such patients.”

The researchers highlighted that while the numbers are ‘too small’ to offer a reliable risk assessment based on varying doses of alteplase, some study protocols have recommended the avoidance of APT for at least 24 hours after alteplase use. [Stroke 2013;44:870-947; Cochrane Database Syst Rev 2014;7:CD000213]

Overall, although nonsignificant, the results suggest a trend towards better clinical outcomes with low-dose vs standard-dose alteplase, said the researchers, who called for randomized trials to elucidate the effects of low-dose and standard-dose alteplase in patients with APT history.

The potential benefits of low-dose alteplase in patients with high sICH risk should also be further investigated, they added.

 

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Most Read Articles
02 Dec 2017
The risk of congenital heart disease (CHD) Is significantly higher in foetuses conceived through in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI), according to a recent study.
Pearl Toh, 4 days ago
A higher dose of pitavastatin can benefit Japanese patients with stable coronary artery disease (CAD) compared with a low-dose pitavastatin, even though cardiovascular (CV) event incidence is known to be lower in Asian than Western patients, according to the REAL-CAD study presented at the AHA Scientific Sessions 2017.
01 Apr 2014
The basic life support (BLS) termination of resuscitation (TOR) rule recommends transport and continued resuscitation when cardiac arrest is witnessed by EMT-Ds, or there is a return of spontaneous circulation, or a shock is given.
03 Dec 2017
Treatment with the triple combination of amlodipine, losartan and rosuvastatin appears to be an effective therapeutic strategy for lowering blood pressure and low-density lipoprotein (LDL)-C levels in patients with comorbid hypertension and dyslipidaemia, according to a study.