Prof Pierre Amarenco (Paris University, Paris, FR) discusses the Ticagrelor Added to Aspirin in Acute Ischemic Stroke or TIA of Atherosclerotic Origin trial.
Patients with tiaa and minor ischemic stroke are at very high risk of subsequent stroke or death and up until now the treatment recommended was aspirin until recently when we had two trials showing that uh dual therapy combining aspirin and ticagrelor was superior to aspirin in two trials one in china performed in china one other performed in north america and
A little bit in europe so leading the american heart american stroke association to recommend in patients with minor stroke or tia to prescribe immediately a clopidogrel pressure spring for 21 days as a at the new gold standard treatment we decided to test a new p212 inhibitor called sicarelor which is well known by cardiologists ticagrelor has an advantage
On clopidogrel because it is not a prodrug it is directly acting and it has a higher platelet elevation and a more sustained platelet inhibition a faster onset quicker offset and also we we have a an antidote now which is in phase 2 and fast track approval by fda so with this background we designed the tallest trial that is trial was a the randomization of
Patients with minor stroke uh or high risk tiaa to either ticagrelor added to aspirin versus aspirin alone plus placebo with a loading dose of tikkarella of 180 milligrams the first day followed by 90 milligram bid for the rest of the 30 days and the loading dose of aspirin 300 milligram followed by 100 milligram the rest of the 90 days at the end point was
Stroke or death and it was judged at 30 days so the key results is that tiger added to aspirin found a significant 17 relative risk reduction as compared to aspirin alone and that there was also an increase his risk of major bleeding a ratio of a minimal absolute risk of major building 0.5 percent in the uh uh ticket price that in arm versus 0.1 in the aspirin
Arm an absolute risk that did not have weighted the benefit observed on stroke or death then we decided to evaluate the efficacy of chicago as aspirin in the subgroup of patients with an ipsilateral stenosis at randomization ipsilateral stenosis meaning that later skerotic stenosis likely causal of their of their stroke and we found that uh about 200 uh 2500
Patients uh had uh an ipsilateral stenosis versus uh 8 600 patients without ipsilateral stenosis and in the group with with ipsilateral stenosis we found that uh the beneficiary effect was much higher since uh the risk on aspirin was 10.9 uh and it was seven point nine percent on tequila pros aspirin so a three percent absolute risk reduction a 27 relative risk
Reduction a number needed to treat of 34. while on in patients without epsilon stenosis there was a 17 relative risk reduction which was not reaching statistical significance but uh probably because of power uh lack of power we did not find a treatment uh by subgroup ipsilateral stenosis interaction we just missed statistical significance but the uh the effect
We observed in the group with ipsilateral stenosis was really meaningful uh with this number needed to treat of 34 and an albanite arm of 906 960 around 960 never needed to arm so um the beneficial risk ratio in the group with ipsilateral stenosis is maximal uh and the the risk is really minimal is this group in fact we had four major uh bleeding uh in the
Group with uh tk kharagpur’s aspirin versus three in the group uh on aspirin alone in patients with ipsilateral stenosis the conclusion is that a ticagrelop has aspirin is superior to aspirin in patients with a ti high risk tia or minor ischemic stroke and that it is also true for a significant reduction of disabling stroke uh in with cyclopress aspirin
Compared to aspirin alone which is really something new and in the subgroup of patients with ipsilateral stenosis we had an even better reduction with a three percent absolute risk reduction a very meaningful uh uh an ability to treat of 34 and a number needed to arm of 960 which is which shows the the that uh the group with ipsilateral stenosis is really the
Group to target uh in with tiger press aspirin but without the herogenity in the treatment by subgroup interaction we we cannot say that the patient without ipsilateral stenosis do not benefit uh from tikka developers aspirin first we have to note that the fda just three days ago gave the approval of chicago plus aspirin over aspirin based on the tallest trial
Results to reduce disabling stroke or death in patients with a high-risk gia or minor ischemic stroke so the next step is really to to have the ema approval or so and the chinese fda approval and also to to have it uh implemented uh in guidelines uh as uh it was for capital press aspirin now the uh the doctors the vascular neurologists who will be able to
Prescribe ticagrelor cause aspirin or clopidogrel press aspirin in the patient we’d have to think about which treatment will be better for their patients and we don’t have yet a head-to-head comparison but based on the fact that clopidogrel is ineffective in 20 to 40 percent of patients because they have a loss of function allele sip to c19 i think that press
Aspirin which is efficacious in hundred percent uh on platelet reactivity uh blockage um i think that uh it’s it is more reassuring for the prescriber to uh to prescribe a ticagrelor plus aspirin we’d say we will see the how the uptake will be because they are questioned of course also also and so it is important to to balance all these parameters for the
Given doctor to to uh to prescribe cicada plus aspirin in that patient with acute minor ischemic stroke or high risk tia you
Transcribed from video
AHA 2020: Findings from the THALES trial — Prof Pierre Amarenco By Radcliffe