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Safety of early antiplatelet administration in patients with acute ischemic stroke treated with alteplase (SEAPT-24)

  • Author Footnotes
    1 731-234-2849
    Drew A. Wells
    Correspondence
    Corresponding author at: Clinical Pharmacy Specialist – Internal Medicine, Department of Pharmacy, Methodist University Hospital, 1265 Union Avenue, Memphis, TN 38104, USA.
    Footnotes
    1 731-234-2849
    Affiliations
    Department of Pharmacy, Methodist Le Bonheur Healthcare - University Hospital, Memphis, TN, USA

    University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
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  • Author Footnotes
    2 901-483-7956
    Lyndsey K. Davis
    Footnotes
    2 901-483-7956
    Affiliations
    University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
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  • Author Footnotes
    3 314-616-8516
    Omar Saeed
    Footnotes
    3 314-616-8516
    Affiliations
    Department of Neurology - University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
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  • Author Footnotes
    4 901-478-2323
    ,
    Author Footnotes
    9 At the time the research was conducted and the manuscript was written, individual author's affiliations were as listed; author is now an employee of Chiesi, USA
    G. Morgan Jones
    Footnotes
    4 901-478-2323
    9 At the time the research was conducted and the manuscript was written, individual author's affiliations were as listed; author is now an employee of Chiesi, USA
    Affiliations
    Department of Pharmacy, Methodist Le Bonheur Healthcare - University Hospital, Memphis, TN, USA

    University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA

    Department of Neurology - University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
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  • Author Footnotes
    5 412-708-9189
    Cheran Elangovan
    Footnotes
    5 412-708-9189
    Affiliations
    Department of Neurology - University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
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  • Author Footnotes
    6 901-448-1596
    Andrei V. Alexandrov
    Footnotes
    6 901-448-1596
    Affiliations
    Department of Neurology - University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
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  • Author Footnotes
    7 901-448-6661
    Balaji Krishnaiah
    Footnotes
    7 901-448-6661
    Affiliations
    Department of Neurology - University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
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  • Author Footnotes
    8 901-478-2313
    Katherine L. March
    Footnotes
    8 901-478-2313
    Affiliations
    Department of Pharmacy, Methodist Le Bonheur Healthcare - University Hospital, Memphis, TN, USA

    University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, USA
    Search for articles by this author
  • Author Footnotes
    1 731-234-2849
    2 901-483-7956
    3 314-616-8516
    4 901-478-2323
    5 412-708-9189
    6 901-448-1596
    7 901-448-6661
    8 901-478-2313
    9 At the time the research was conducted and the manuscript was written, individual author's affiliations were as listed; author is now an employee of Chiesi, USA

      Abstract

      Objectives

      Alteplase, a tissue-type plasminogen activator, is recommended for ischemic stroke patients presenting within 4.5 h. Due to bleeding risks, current guidelines advise delaying antiplatelet therapy for 24 h after alteplase. However, specific scenarios may require antiplatelet therapy to be given within the 24 h window. This study aimed to examine the safety of early antiplatelet therapy administration within the first 24 h after alteplase.

      Materials and methods

      This study is a retrospective, observational study of adult patients with acute ischemic stroke who received alteplase across a multi-hospital system. Patients were grouped based on early antiplatelet therapy (within 24 h window) or as recommended per guidelines. The occurrence of bleeding events, including symptomatic intracranial hemorrhage and/or gastrointestinal bleeding, in-hospital mortality, unfavorable outcomes (modified Rankin score 3–6), and hospital length of stay, were compared between groups.

      Results

      Patients were predominantly African American (72%) and female (53%) with a median age of 62 years. Median baseline NIHSS scores were higher in the early group (5 vs. 7; p = 0.04), and patients in the early group were more likely to undergo endovascular therapy (26% vs. 8%, p < 0.0001). In patients treated with alteplase only and who did not undergo endovascular therapy, there was no difference in symptomatic intracranial hemorrhage (1.4% vs. 0%, p = 0.1), gastrointestinal bleeding, in-hospital mortality, unfavorable outcomes, or length of stay.

      Conclusions

      In our retrospective analysis, early administration of antiplatelet therapy (< 24 h post-alteplase) did not increase the risk of symptomatic intracranial hemorrhage, gastrointestinal bleeding, or unfavorable outcomes in patients who received alteplase alone for management of acute ischemic stroke. Prospective studies are needed to validate these findings.

      Keywords

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      References

        • Chatterjee S.
        • National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group
        Tissue plasminogen activator for acute ischemic stroke.
        N Engl J Med. 1995 Dec 14; 333: 1581-1587
        • Guidetti D
        • Larrue V
        • Lees K.R
        • et al.
        Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke.
        N Engl J Med. 2011; (Published online): 1317-1329
        • Thomalla G
        • Simonsen CZ
        • Boutitie F
        • et al.
        MRI-guided thrombolysis for stroke with unknown time of onset.
        N Engl J Med. 2018; 379: 611-622https://doi.org/10.1056/nejmoa1804355
        • International Stroke Trial Collaborative Group
        The international stroke trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke.
        Lancet. 1997; 349: 1569-1581
      1. CAST (Chinese Acute Stroke Trial) Collaborative Group. CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke.
        Lancet. 1997; 349: 1641-1649
        • Powers WJ
        • Rabinstein AA
        • Ackerson T
        • et al.
        Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the earlymanagement of acute ischemic stroke: a guideline for healthcare professionals from the american heart association/american stroke association.
        Stroke. 2019; 50: e344-e418https://doi.org/10.1161/STR.0000000000000211
        • Zinkstok SM
        • Roos YB.
        Early administration of aspirin in patients treated with alteplase for acute ischaemic stroke: a randomised controlled trial.
        Lancet. 2012; 380: 731-737https://doi.org/10.1016/S0140-6736(12)60949-0
        • Jeong HG
        • Kim BJ
        • Yang MH
        • Han MK
        • Bae HJ
        • Lee SH.
        Stroke outcomes with use of antithrombotics within 24 hours after recanalization treatment.
        Neurology. 2016; 87: 996-1002https://doi.org/10.1212/WNL.0000000000003083
        • Harris PA
        • Taylor R
        • Minor BL
        • et al.
        The REDCap consortium: building an international community of software platform partners.
        J Biomed Inform. 2019; 95103208https://doi.org/10.1016/j.jbi.2019.103208
        • Harris PA
        • Taylor R
        • Thielke R
        • Payne J
        • Gonzalez N
        • Conde JG.
        Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381https://doi.org/10.1016/j.jbi.2008.08.010
        • Wahlgren N
        • Ahmed N
        • Dávalos A
        • et al.
        Thrombolysis with alteplase for acute ischaemic stroke in the safe implementation of thrombolysis in stroke-monitoring study (SITS-MOST): an observational study.
        Lancet. 2007; 369https://doi.org/10.1016/S0140-6736(07)60149-4
        • Semba CP
        • Bakal CW
        • Calis KA
        • et al.
        Alteplase as an alternative to urokinase.
        J Vasc Interv Radiol. 2000; 11https://doi.org/10.1016/S1051-0443(07)61418-3
        • Awtry EH
        • Loscalzo J.
        Aspirin.
        Circulation. 2000; 101: 1206-1218https://doi.org/10.1161/01.CIR.101.10.1206
        • Uyttenboogaart M
        • Koch MW
        • Koopman K
        • Vroomen PCAJ
        • De Keyser J
        • Luijckx GJ.
        Safety of antiplatelet therapy prior to intravenous thrombolysis in acute ischemic stroke.
        Arch Neurol. 2008; 65: 607-611https://doi.org/10.1001/archneur.65.5.noc70077
        • Li X-Q
        • Cui Y
        • Wang X-H
        • Chen H-S.
        Early antiplatelet for minor stroke following thrombolysis (EAST): rationale and design.
        Int J Stroke. 2022; (Published online July 2817474930221118900)https://doi.org/10.1177/17474930221118900
        • Saver JL
        • Goyal M
        • Bonafe A
        • et al.
        Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.
        N Engl J Med. 2015; 372: 2285-2295https://doi.org/10.1056/nejmoa1415061
        • Jovin TG
        • Chamorro A
        • Cobo E
        • et al.
        Thrombectomy within 8 hours after symptom onset in ischemic stroke.
        N Engl J Med. 2015; 372https://doi.org/10.1056/nejmoa1503780
        • Campbell BCV
        • Mitchell PJ
        • Kleinig TJ
        • et al.
        Endovascular therapy for ischemic stroke with perfusion-imaging selection.
        N Engl J Med. 2015; 372https://doi.org/10.1056/nejmoa1414792
        • Bracard S
        • Ducrocq X
        • Mas JL
        • et al.
        Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial.
        Lancet Neurol. 2016; 15: 1138-1147https://doi.org/10.1016/S1474-4422(16)30177-6
        • LeCouffe NE
        • Kappelhof M
        • Treurniet KM
        • et al.
        A randomized trial of intravenous alteplase before endovascular treatment for stroke.
        N Engl J Med. 2021; 385: 1833-1844https://doi.org/10.1056/nejmoa2107727
        • Berkhemer OA
        • Fransen PSS
        • Beumer D
        • et al.
        A randomized trial of intraarterial treatment for acute ischemic stroke.
        N Engl J Med. 2015; 372: 11-20https://doi.org/10.1056/nejmoa1411587
        • Brandel MG
        • Elsawaf Y
        • Rennert RC
        • et al.
        Antiplatelet therapy within 24 hours of tPA: lessons learned from patients requiring combined thrombectomy and stenting for acute ischemic stroke.
        J Cerebrovasc Endovasc Neurosurg. 2020; 22: 1-7https://doi.org/10.7461/jcen.2020.22.1.1
        • Binning MJ
        • Maxwell CR
        • McAree M
        • et al.
        The use of antiplatelet agents and heparin in the 24-hour postintravenous alteplase window for neurointervention.
        Neurosurgery. 2021; 88: 746-750https://doi.org/10.1093/neuros/nyaa530
        • Wahlgren N
        • Ahmed N
        • Eriksson N
        • et al.
        Multivariable analysis of outcome predictors and adjustment of main outcome results to baseline data profile in randomized controlled trials: safe implementation of thrombolysis in stroke-monitoring study (SITS-MOST).
        Stroke. 2008; 39https://doi.org/10.1161/STROKEAHA.107.510768