Background & Purpose: In a recent randomized controlled trial (RCT) of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) antiplatelet pre-treatment (APP) was associated with adverse outcomes. We conducted a systematic review and meta-analysis of available RCTs to investigate the association of APP with outcomes of AIS patients treated with IVT.
Methods: The outcome events of interest included symptomatic intracranial hemorrhage (sICH), complete recanalization (CR), 3-month favorable functional outcome (FFO, mRS-score: 0-1), functional independence (FI, mRS-score: 0-2), and mortality. Both unadjusted and adjusted (for baseline stroke severity and age) analyses were performed using random effects methodology.
Results: We included 8 RCTs (5,332 total patients, 34% with APP). In unadjusted analyses (Figure 1), APP was associated with higher likelihood of sICH (OR=2.01, 95%CI: 1.53-2.63) and death (OR=1.59, 95%CI: 1.24-2.03; 1C) and lower likelihood of 3-month FI (OR=0.69, 0.56-0.85). No association was detected between APP and 3-month FFO (OR=0.79, 95%CI: 0.58-1.07) and CR (OR=0.64, 95%CI: 0.04-11.66). In adjusted analyses (Figure 2), APP was related to higher odds of sICH (OR=1.89, 95%CI: 1.14-3.12). There was no association between APP and 3-month FI (OR=0.94, 95%CI: 0.70-1.26) or death (OR=1.01, 95%CI: 0.55-1.86). In all analyses no evidence of heterogeneity was detected.
Conclusion: Despite APP association with a higher risk of sICH after thrombolysis, three-month functional outcomes appear un-affected by APP. APP before IVT should not be used as an excuse to withhold or to lower the dose of IVT.