Among patients with a TIA or minor ischaemic strokes, ipsilateral atherosclerotic stenosis of cervicocranial vasculature entails the highest risk of recurrent vascular events, explained first author Prof. Pierre Amarenco (Paris University, France) [2]. Ticagrelor monotherapy was not superior to aspirin in the SOCRATES trial [3]. However, in the subgroup of patients with ipsilateral atherosclerotic stenosis, ticagrelor was superior to aspirin [4].
The THALES trial (NCT03354429) randomised 11,016 patients to ticagrelor (180 mg loading dose on day 1 followed by 90 mg twice daily for days 2â30) or placebo added to aspirin (300â325 mg on day 1 followed by 75â100 mg daily for days 2â30). Previously published results showed that ticagrelor added to aspirin was superior to aspirin alone for the prevention of stroke or death (5.5% vs 6.6%; HR 0.83; P=0.015) [5]. Prof. Amarenco presented results of a prespecified subgroup of the THALES, including 2,351 (21.3%) patients with ipsilateral, potentially causal atherosclerotic stenosis with â„30% of cervicocranial vasculature.
The primary endpoint, time to stroke or death within 30 days, occurred in 92 of 1,136 (8.1%) patients in the ticagrelor group versus 132 of 1,215 (10.9%) in the placebo group (HR 0.73; 95% CI 0.56â0.96; P=0.023). In patients without ipsilateral stenosis, the corresponding event rate was 211 of 4,387 (4.8%) and 230 of 4,278 (5.3%), respectively (HR 0.89; 95% CI 0.74â1.08; P=0.23, Pinteraction=0.245); see Figure. In patients with ipsilateral atherosclerotic stenosis, severe bleeding (GUSTO definition) occurred in 4 (0.4%) in participants on ticagrelor and 3 (0.2%) participants on placebo, respectively. In patients without ipsilateral atherosclerotic stenosis (n=8,665) severe bleeding occurred in 24 (0.5%) and 4 (0.1%) participants, respectively (HR 5.87; 95% CI 2.04â16.90, P=0.001).
Figure: 30-day absolute event rate of stroke or death in THALES
Prof. Amarenco concluded that in patients with ipsilateral atherosclerotic stenosis, 30-day absolute event rate of stroke or death was higher (10.9% on aspirin alone) and absolute risk reduction was greater on ticagrelor added to aspirin (3.0%) than in patients with no ipsilateral stenosis (5.3% and 0.5%, respectively). He added that these findings are concordant with prior studies, suggesting that atherosclerotic disease carries a greater risk than other stroke subtypes without stenosis among patients with TIA or minor ischaemic stroke events on aspirin. âGiven both the SOCRATES and THALES results, targeting patients with atherosclerotic stenosis for dual therapy with ticagrelor and aspirin could yield a clinically meaningful relative and absolute risk reduction of stroke and death as compared with aspirin alone with a number needed to treat of 34 (95% CI 19â171) and a number needed to harm of 951.â
- Amarenco P, et al. Ticagrelor Added to Aspirin in Acute Ischemic Stroke or Tia of Atherosclerotic Origin. LBS.03, AHA Scientific Sessions 2020, 13â17 Nov.
- Amarenco P, et al. N Engl J Med 2016;374:1533â1534.
- Johnston SC, et al. N Engl J Med. 2016;375:35â43.
- Amarenco P, et al. Lancet Neurol. 2017;16:301â310.
- Johnston SC, et al. N Engl J Med. 2020;383:207â217.
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Table of Contents: AHA 2020
Featured articles
COVID-19 and Influenza
Fewer CV complications than expected in AHA COVID-19 Registry
Worse COVID-19 outcomes in younger obese patients
Effects of CVD in hospitalised COVID-19 patients
Unfavourable outcomes for COVID-19 patients with AF and atrial flutter
High-dose influenza vaccine in patients with CVD
Atrial Fibrillation
Vitamin D or omega 3 fatty acids do not prevent AF
Active screening for AF improves clinical outcomes
AF screening in older adults at primary care visits
CVD Risk Reduction
Clever trial design gets patients back on statins: the SAMSON trial
Polypill plus aspirin reduces cardiovascular events
Lowering LDL cholesterol in older patients is beneficial
No CV benefit from omega 3 in high-risk patients
Safety and efficacy of inclisiran for hypercholesterolemia
Remote risk management programme effective and efficient
Healthy lifestyle lowers mortality irrespective of medication burden
Heart Failure
Omecamtiv mecarbil improves outcomes in HFrEF-patients
IV iron reduces HF hospitalisation
Dapagliflozin reduces renal risk independent of CV disease status
âStrongly consider an SGLT2-inhibitor in most T2DM patientsâ
Additional HFrEF education and patient-engagement tools
Acute Coronary Syndrome
No benefit from omega-3 fatty acids after recent MI
PIONEER III trial: Drug-eluting stents comparable
Coronary and Valve Disease
Extra imaging reveals cause of MINOCA in women
Ticagrelor not superior to clopidogrel after elective PCI
Stroke
Ticagrelor/aspirin reduces stroke risk in patients with ipsilateral cervicocranial plaque
AF monitoring following cardiovascular surgery
Miscellaneous
PAD: Rivaroxaban reduces VTE risk after revascularisation
Sotatercept: potential new treatment option for PAH
Finerenone lowers CV events in diabetic CKD patients
Mavacamten effective in obstructive hypertrophic cardiomyopathy
Children exposed to tobacco smoke have worse heart function as adults
Transgender people have unaddressed heart disease risks
Intensive blood pressure lowering benefits older adults
Longer chest compression pause worsens outcomes after paediatric IHCA
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