NIHSS and Large Artery Atherosclerosis Affect Efficacy of Dual Antiplatelet Therapy Versus Alteplase for Minor Stroke.

backgroundDual antiplatelet therapy (DAPT) was noninferior to alteplase in nondisabling minor stroke (NIHSS 0 to 5). Given potential benefit of DAPT in minor stroke with large artery atherosclerosis (LAA) and of alteplase in stroke with NIHSS 4-5, we hypothesize that neurological deficit and LAA may affect efficacy of DAPT versus alteplase in minor stroke.

methodsThis analysis included patients from the ARAMIS trial with minor stroke who underwent vessel imaging assessment. Participants were stratified into NIHSS 0-3 with LAA, NIHSS 0-3 with Non-LAA, NIHSS 4-5 with LAA, and NIHSS 4-5 with Non-LAA. Outcomes were compared between those receiving DAPT versus alteplase. Primary outcome was an excellent functional outcome (mRS 0 to 1) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and bleeding events. Primary analysis employed adjusted models, with sensitivity analysis conducted using inverse probability of treatment weighting.

resultsAmong 478 included patients, including 388 in NIHSS 0-3 group and 90 in NIHSS 4-5 group. In NIHSS 0-3 group, a numerically higher rates of excellent functional outcome was found in patients with LAA who received DAPT versus alteplase (97.3% vs. 85.1%; adjusted OR, 6.45 [0.68 to 60.81]; p = 0.10), which was obviously attenuated in patients with Non-LAA (96.5% vs. 94.4%; adjusted OR, 1.67 [0.50 to 5.59]; p = 0.41). This phenomenon was not observed in NIHSS 4-5 group, and the test for interaction was not statistically significant (p-interaction = 0.36). Notably, sensitivity analysis revealed that DAPT significantly increased the likelihood of excellent functional outcome in the NIHSS 0-3 with LAA subgroup (adjusted OR, 6.49 [1.54 to 27.39]; p = 0.01), but not in NIHSS 0-3 with Non-LAA subgroup (adjusted OR, 2.51 [0.58 to 10.90]; p = 0.22). Safety outcomes were comparable across treatments.

conclusionsNeurological deficit and LAA may affect efficacy of DAPT versus alteplase in acute minor nondisabling stroke. In patients with NIHSS scores of 0 to 3 due to LAA, DAPT may be associated with numerically higher odds of 90-day functional outcomes compared to alteplase. Given the exploratory nature of this subgroup analysis and no formal adjustment for multiple comparisons was applied, these results should be interpreted as hypothesis-generating and require confirmation.