DAPT works better than intravenous alteplase for preventing END after stroke

For patients with minor nondisabling acute ischaemic stroke without large vessel occlusion (LVO), dual antiplatelet therapy (DAPT) appears to prevent early neurological deterioration (END) with superior efficacy compared with intravenous alteplase while having a better safety profile, according to a post hoc analysis of the ARAMIS* trial.

The post hoc analysis included patients with responsible vessel examination in the as-treated analysis set of the ARAMIS trial. These patients were grouped according to the presence of large vessel occlusion (LVO group and non-LVO group) and according to the treatment received (DAPT group and intravenous alteplase group).

The primary outcome of END at 24 hours was defined as at least a 4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score from baseline. Safety outcomes included symptomatic intracerebral haemorrhage and bleeding events.

A total of 480 out of 723 patients who participated in the ARAMIS trial were included in the post hoc analysis. Of these, 36 were in the LVO group and 444 in the non-LVO group, of whom 20 patients had END.

Compared with intravenous alteplase, DAPT was associated with a lower risk of END in the non-LVO group (adjusted risk difference, −4.8 percent, 95 percent confidence interval [CI], −6.9 to −2.6; p<0.001) but not in the LVO group (adjusted risk difference, 2.3 percent, 95 percent CI, −17.6 to 22.3; p=0.82). The interaction was borderline significant (p=0.06).

In terms of safety, DAPT was likewise associated with a lower likelihood of bleeding events compared with intravenous alteplase in the non-LVO group (adjusted risk difference, −6.4 percent, 95 percent CI, −8.9 to −3.9; p<0.001). Other safety outcomes did not significantly differ between the two treatment groups.

*Antiplatelet Versus R-tPA for Acute Mild Ischemic Stroke