Wayneho Kam, MD
The current standard of practice is to avoid the use of antithrombotic agents within the first 24 hours after receiving intravenous thrombolytics. This is due to concern that the concurrent use of antiplatelets or anticoagulants with recent thrombolytic administration may increase the risk for bleeding events. The concern may be unfounded, however, particularly given the relatively short half-life of alteplase.
There are instances, of course, when use of such medications within 24 hours of alteplase administration may be warranted, such as with concomitant endovascular therapy with stent placement or acute myocardial infarction.
What if early neurological deterioration occurs in patients after they received tPA, in the absence of a clear explanation, such as hemorrhagic conversion or cerebral edema? Will these patients benefit from early initiation of antiplatelet therapy?
The study by Wu et al. seeks to address this question. In their retrospective analysis of prospectively collected data of 1764 consecutive patients with acute ischemic stroke treated with tPA, 187 patients who experienced early neurological deterioration were eligible for the study, and 121 of these individuals were treated with tirofiban within the first 24 hours after tPA. Adjusted multivariate analysis showed that early tirofiban use was not associated with adverse events, including symptomatic intracranial hemorrhage (adjusted odds ratio [aOR], 1.05; 95% CI, 0.088-11.02; P=1.000), ICH (aOR, 1.13; 95% CI, 0.45-4.25; P=0.512), or mortality (aOR, 0.77; 95% CI, 0.19-2.27; P=0.875), but rather significantly associated with excellent (aOR, 2.24; 95% CI, 1.16-3.94; P=0.027) and favorable (aOR, 2.31; 95% CI, 1.48-3.99; P=0.011) functional outcomes as measured by modified Rankin Scale at 3 months (≤1 or ≤2, respectively).
This study has its limitations, mainly that it is an exploratory analysis and not a randomized controlled trial, subject to selection bias by design. Nevertheless, the results of the study are promising in that patients who experience early neurological deterioration after having received tPA (presumably because it did not work) may benefit from early administration of short-acting antiplatelet therapies, as a bridge to their longer-term, maintenance antithrombotic regimen.