Is dual antiplatelet therapy for mild stroke just as effective as thrombolytic therapy?

Question:

Is dual antiplatelet therapy for mild stroke just as effective as thrombolytic therapy?

The Study

A study was published in the Journal of the American Medical Association (JAMA) in June, 2023 to answer this question.

The study followed 760 adults with acute stroke and an NIHSS score < 5 AND < 1 point on “single-item scores, such as vision, language, neglect, or single limb weakness, and a score of 0 in the consciousness item at the time of randomization”

• Partcipants must have undergone CT or MRI brian imaging and must have presented to the hospital within 4.5 hours of symptom onset.
• Partcipants were then randomized to receive either thrombolytic treatment with alteplase, or dual antiplatelet therapy with aspirin and clopidogrel.

The primary outcome measured was: Excellent functional outcome at 90 days

The secondary outcomes measured were:

• Favorable functional outcome at 90 days
• Change in NIHSS score at 24 hours
• Early neurological improvement at 24 hours
• Early neurological deterioration at 24 hours
• New stroke or other vascular events at 90 days
• 90-day all-cause mortality
• Ordinal shift of the mRS score at 90 days.

The safety outcomes measured were symptomatic intra-cranial hemorrhage (sICH) and any bleeding event during the study.

What did they find?

93.8% of patients (346/369) of the DAPT group and 91.4% (320/350) of the alteplase group had an excellent functional outcome at 90 days.

Symptomatic intracerebral hemorrhage occurred in 1 of 371 participants (0.3%) in the DAPT group and 3 of 351 (0.9%) in the alteplase group, at 90 days.

Conclusion

“Among patients with minor nondisabling acute ischemic stroke presenting within 4.5 hours of symptom onset, DAPT was noninferior to intravenous alteplase with regard to excellent functional outcome at 90 days.”

Read the original article:

Chen HS, Cui Y, Zhou ZH, Zhang H, Wang LX, Wang WZ, Shen LY, Guo LY, Wang EQ, Wang RX, Han J, Dong YL, Li J, Lin YZ, Yang QC, Zhang L, Li JY, Wang J, Xia L, Ma GB, Lu J, Jiang CH, Huang SM, Wan LS, Piao XY, Li Z, Li YS, Yang KH, Wang DL, Nguyen TN; ARAMIS Investigators. Dual Antiplatelet Therapy vs Alteplase for Patients With Minor Nondisabling Acute Ischemic Stroke: The ARAMIS Randomized Clinical Trial. JAMA. 2023 Jun 27;329(24):2135-2144. doi: 10.1001/jama.2023.7827. PMID: 37367978; PMCID: PMC10300686.