Adapted antiplatelet therapy and ischemic events after stenting for intracranial aneurysms

Anti-platelet adjustments, controlled by monitoring of platelet function, reduced thromboembolic events, but exacerbated minor or minimal bleeding events in patients with unruptured intracranial aneurysm (UIA) after stenting, according to study results published in Stroke.

After neurointerventional procedures, thromboembolic events are the most common cause of morbidity. In patients undergoing stenting for a cerebral aneurysm, standard dual antiplatelet therapy (DAPT) – a combination of 100 mg aspirin and 75 mg clopidogrel – is important to reduce thromboembolic events. However, according to the researchers, some patients with high platelet reactivity (HPR) during treatment tend to be at increased risk of thromboembolic events due to inadequate platelet inhibition. Monitoring platelet function could help improve clinical outcomes by measuring platelet reactivity so that antiplatelet therapy can be adjusted accordingly.

The aim of the current study was to determine whether platelet function monitoring-driven adjustment of antiplatelet drugs could improve clinical outcomes in stented UIA patients compared to patients receiving standard DAPT without platelet function monitoring.

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The open study included 314 patients (mean age 56.1 years) with UIA who underwent stent placement in a hospital in China. Patients were randomly assigned to either DAPT adjustment with platelet function monitoring (n = 157) or standard DAPT treatment without platelet function monitoring (n = 157).

In the monitoring group, patients were monitored for platelet function 1 day prior to intracranial stent placement. Standard light transmission aggregometry was used to measure platelet aggregation. A second monitoring was performed 2 weeks after randomization in patients assigned a drug adjustment.

Patients who developed HPR under 75 mg clopidogrel switched to a dose of 180 mg ticagrelor before the procedure and to 2 additional daily doses of 90 mg ticagrelor after the procedure. Aspirin doses were increased to 200 mg in patients with HPR taking aspirin. Treatment adjustments were made ≥ 1 day prior to stent placement.

A combined incidence of ischemic stroke, transient ischemic attack, stent thrombosis, urgent revascularization, and cerebrovascular death within 7 days of stenting was the primary endpoint. The researchers also rated safety based on a composite frequency of major, minor, or minimal bleeding within a month after stenting.

A significantly larger proportion of patients in the conventional group experienced the primary composite endpoint compared to those in the monitoring group (12.1% and 5.1%, respectively; hazard ratio) [HR], 0.39; 95% CI, 0.17-0.92; P = .03). In addition, the frequency of ischemic stroke was lower in the drug monitoring group (4.5% vs. 12.1%; HR 0.34; 95% CI, 0.14-0.83; P = 0.01), which is the According to researchers, “affects the primary combined overall result”. “

The combined safety outcome occurred in a larger proportion of patients who were assigned a DAPT adjustment under the control of platelet function monitoring (7.0% vs. 1.9%; HR 3.87; 95% CI 1.06– 14.14; P = 0.03).

There was also a significant difference between the surveillance group and the conventional group in terms of the frequency of minor or minimal bleeding events (6.4% and 1.3%, respectively; HR 5.27; 95% CI 1.14-24.45: P = 0.02), but there was no difference between groups in major bleeding rates (0.6% for both; HR 1.00; 95% CI 0.06–16.13; P = 1.0 ).

Limitations of the study included the open design as well as the inclusion of patients from a single center in China, suggesting that the results may not be generalized to other patient populations.

Despite these limitations, the researchers concluded that their results “suggest that guided antiplatelet therapy may be a safe and attractive alternative treatment option for UIA patients who have undergone stenting.”

reference

W. Li, W. Zhu, A. Wang et al. Effect of an adapted antiplatelet therapy on the prevention of ischemic events after stenting in intracranial aneurysms. Stroke. Published online September 20, 2021. doi: 10.1161 / STROKEAHA.120.032989