Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia
Abstract Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In...
| Main Authors: | , , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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Nature Portfolio
2023-07-01
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| Series: | Scientific Reports |
| Online Access: | https://doi.org/10.1038/s41598-023-38474-2 |
| _version_ | 1797774234959740928 |
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| author | Lisa J. Woodhouse Jason P. Appleton Hanne Christensen Rob A. Dineen Timothy J. England Marilyn James Kailash Krishnan Alan A. Montgomery Anna Ranta Thompson G. Robinson Nikola Sprigg Philip M. Bath |
| author_facet | Lisa J. Woodhouse Jason P. Appleton Hanne Christensen Rob A. Dineen Timothy J. England Marilyn James Kailash Krishnan Alan A. Montgomery Anna Ranta Thompson G. Robinson Nikola Sprigg Philip M. Bath |
| author_sort | Lisa J. Woodhouse |
| collection | DOAJ |
| description | Abstract Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24–3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8–35 day period but not in the 0–7 or 36–90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains. Trial registration ISRCTN47823388 . |
| first_indexed | 2024-03-12T22:18:05Z |
| format | Article |
| id | doaj.art-9c7b9b2006c74f83a10cb29284475d26 |
| institution | Directory Open Access Journal |
| issn | 2045-2322 |
| language | English |
| last_indexed | 2024-03-12T22:18:05Z |
| publishDate | 2023-07-01 |
| publisher | Nature Portfolio |
| record_format | Article |
| series | Scientific Reports |
| spelling | doaj.art-9c7b9b2006c74f83a10cb29284475d262023-07-23T11:12:38ZengNature PortfolioScientific Reports2045-23222023-07-0113111610.1038/s41598-023-38474-2Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemiaLisa J. Woodhouse0Jason P. Appleton1Hanne Christensen2Rob A. Dineen3Timothy J. England4Marilyn James5Kailash Krishnan6Alan A. Montgomery7Anna Ranta8Thompson G. Robinson9Nikola Sprigg10Philip M. Bath11Stroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen’s Medical Centre, University of NottinghamStroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen’s Medical Centre, University of NottinghamBispebjerg and Frederiksberg Hospital, Department of Neurology, University of CopenhagenRadiological Sciences, Mental Health and Clinical Neuroscience, School of Medicine, Queens Medical Centre, University of NottinghamStroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen’s Medical Centre, University of NottinghamNottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of NottinghamStroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen’s Medical Centre, University of NottinghamNottingham Clinical Trials Unit, Applied Health Research Building, School of Medicine, University of NottinghamDepartment of Medicine, University of OtagoDepartment of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, University of LeicesterStroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen’s Medical Centre, University of NottinghamStroke Trials Unit, Mental Health and Clinical Neuroscience, School of Medicine, South Block D Floor, Queen’s Medical Centre, University of NottinghamAbstract Intensive antiplatelet therapy did not reduce recurrent stroke/transient ischaemic attack (TIA) events as compared with guideline treatment in the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) trial, but did increase the frequency and severity of bleeding. In this pre-specified analysis, we investigated predictors of bleeding and the association of bleeding with outcome. TARDIS was an international prospective randomised open-label blinded-endpoint trial in participants with ischaemic stroke or TIA within 48 h of onset. Participants were randomised to 30 days of intensive antiplatelet therapy (aspirin, clopidogrel, dipyridamole) or guideline-based therapy (either clopidogrel alone or combined aspirin and dipyridamole). Bleeding was defined using the International Society on Thrombosis and Haemostasis five-level ordered categorical scale: fatal, major, moderate, minor, none. Of 3,096 participants, bleeding severity was: fatal 0.4%, major 1.5%, moderate 1.2%, minor 11.4%, none 85.5%. Major/fatal bleeding was increased with intensive as compared with guideline therapy: 39 vs. 17 participants, adjusted hazard ratio 2.21, 95% CI 1.24–3.93, p = 0.007. Bleeding events diverged between treatment groups in the 8–35 day period but not in the 0–7 or 36–90 day epochs. In multivariate analysis more, and more severe, bleeding events were seen with increasing age, female sex, pre-morbid dependency, increased time to randomisation, prior major bleed, prior antiplatelet therapy and in those randomised to triple vs guideline antiplatelet therapy. More severe bleeding was associated with worse clinical outcomes across multiple physical, emotional and quality of life domains. Trial registration ISRCTN47823388 .https://doi.org/10.1038/s41598-023-38474-2 |
| spellingShingle | Lisa J. Woodhouse Jason P. Appleton Hanne Christensen Rob A. Dineen Timothy J. England Marilyn James Kailash Krishnan Alan A. Montgomery Anna Ranta Thompson G. Robinson Nikola Sprigg Philip M. Bath Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia Scientific Reports |
| title | Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia |
| title_full | Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia |
| title_fullStr | Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia |
| title_full_unstemmed | Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia |
| title_short | Bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia |
| title_sort | bleeding with intensive versus guideline antiplatelet therapy in acute cerebral ischaemia |
| url | https://doi.org/10.1038/s41598-023-38474-2 |
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