From the Guidelines
Ticagrelor should not be considered as a first-line treatment for stroke management, but rather as an option for specific high-risk patients, such as those with a history of prior MI, who have tolerated DAPT without bleeding complications, as evidenced by the PEGASUS-TIMI 54 trial 1. When considering the role of ticagrelor in stroke management, it's essential to weigh the benefits of reduced ischemic events against the increased risk of major bleeding.
- The PEGASUS-TIMI 54 trial 1 demonstrated that ticagrelor decreased the incidence of ischemic events in patients with a history of prior MI, but also increased the incidence of major bleeding.
- The 2016 ACC/AHA update and the 2017 ESC update both recommend continued DAPT with ticagrelor in patients with MI and high ischemic risk who have tolerated DAPT without bleeding complications, with a COR IIb, LOE B 1.
- However, for acute ischemic stroke, the evidence is less clear, and ticagrelor is not typically considered a first-line treatment option.
- Aspirin or clopidogrel remain the standard first-line options for most stroke patients, due to their more established safety and efficacy profiles.
- Ticagrelor's potent inhibition of platelet aggregation, via reversible binding to P2Y12 receptors, may be beneficial in specific high-risk patients, but its increased risk of bleeding must be carefully considered, particularly in patients with a history of intracranial hemorrhage or recent major bleeding.
From the Research
Role of Ticagrelor in Stroke Management
- Ticagrelor is an effective antiplatelet therapy for patients with coronary atherosclerotic disease and might be more effective than aspirin in preventing recurrent stroke and cardiovascular events in patients with acute cerebral ischaemia of atherosclerotic origin 2.
- A systematic review and meta-analysis found that ticagrelor reduced the risk of stroke, especially ischemic stroke, with significant safety risks, and was slightly better than clopidogrel and aspirin in preventing stroke 3.
- The SOCRATES trial found that ticagrelor was not superior to aspirin in reducing the rate of stroke, myocardial infarction, or death at 90 days in patients with acute ischemic stroke or transient ischemic attack 4.
- A meta-analysis found that ticagrelor reduced the risk of ischemic stroke, combined ischemic and hemorrhagic strokes, and composite stroke/myocardial infarction/cardiovascular death, with no increased risk of mortality or major bleeding events 5.
- A network meta-analysis found that ticagrelor plus aspirin significantly reduced the risk of ischemic stroke, but treatment with ticagrelor monotherapy did not significantly affect ischemic stroke, and the benefit of ticagrelor may come with an increased bleeding risk 6.
Efficacy of Ticagrelor in Preventing Stroke
- Ticagrelor has been shown to reduce the risk of stroke, especially ischemic stroke, in patients with acute cerebral ischaemia of atherosclerotic origin 2, 3.
- The risk of ischemic stroke was reduced by 20% with ticagrelor plus aspirin compared to controls 6.
- Ticagrelor was found to be slightly better than clopidogrel and aspirin in preventing stroke, especially ischemic stroke, with significant safety risks 3.
Safety of Ticagrelor in Stroke Management
- Ticagrelor was not associated with an increased risk of major bleeding events or mortality in some studies 2, 4, 5.
- However, a network meta-analysis found that the benefit of ticagrelor may come with an increased bleeding risk, including intracranial bleeding 6.
- The risk of major bleeding was found to be similar with antiplatelet monotherapies, but twice higher with combined antiplatelet therapies 6.