Key result
Changing treatment to ticagrelor in clopidogrel non-responders after emergent carotid stenting was associated with a higher rate of favorable 90-day outcomes compared to clopidogrel responders (82% vs 57%; OR 3.89, 95% CI 1.09-13.86; p=0.036).
Why the study?
Antiplatelet therapy after emergent carotid stenting involves balancing risks of intracerebral hemorrhages and in-stent thrombosis, and platelet function monitoring could potentially improve outcomes.
Does switching to ticagrelor improve 90-day favorable outcomes in clopidogrel non-responders undergoing emergent carotid artery stenting compared to clopidogrel responders?
Observational (n=105)
No
Does switching to ticagrelor improve 90-day favorable outcomes in clopidogrel non-responders undergoing emergent carotid artery stenting compared to clopidogrel responders?
Platelet-function-monitoring-guided therapy with a switch to ticagrelor in clopidogrel non-responders is safe and associated with improved 90-day clinical outcomes after emergent carotid artery stenting.
May support platelet-guided ticagrelor after carotid stenting; leaves open need for randomized confirmation.
Background/Objectives: Antiplatelet therapy after emergent carotid stenting (eCAS) represents a challenge in balancing the risk of intracerebral hemorrhages (ICHs) and in-stent thrombosis (IST). Post-procedural platelet function monitoring may guide antiplatelet therapy and could potentially improve outcomes due to fewer post-procedural complications. Methods: Consecutive eCAS patients (2019–2021) were included in a single-center retrospective observational study. Patients treated with eCAS received peri-procedural eptifibatide followed by dual antiplatelet treatment with aspirin and clopidogrel. The effect of platelet ADP inhibition by clopidogrel was monitored using the Multiplate® Analyzer (Roche). Clopidogrel non-responders were changed to ticagrelor treatment. The primary outcome was defined as a favorable outcome at 90 days using the modified Rankin Scale (mRS) of 0–2 versus 3–6. Safety outcomes included ICH, IST, and mortality. Data were analyzed and compared in clopidogrel- and ticagrelor-treated patients using Fischer’s exact test and multivariate logistic regression. Results: A total of 105 patients had eCAS, and 28 patients (27%) were clopidogrel non-responders and were changed to treatment with ticagrelor. The favorable outcome was more frequent in ticagrelor-treated patients, 23 (82%), than in clopidogrel-treated patients, 44 (57%), p = 0.036. Numerically, ICH, IST, and mortality were more frequent in clopidogrel-treated patients, but none of the differences were statistically significant. In multivariate analyses, ticagrelor treatment was significantly associated with the favorable outcome, OR = 3.89 (95% CI: 1.09–13.86), p = 0.036. Conclusions: One in four eCAS patients were clopidogrel non-responders. This study suggests that personalized antiplatelet treatment therapy was safe, and that changing treatment to ticagrelor in clopidogrel non-responders was associated with better outcomes in eCAS patients.
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Kreiberg et al. (2024) conducted an observational in Emergent carotid stenting (eCAS) (n=105). Ticagrelor (in clopidogrel non-responders) vs. Clopidogrel (in responders) was evaluated on Favorable outcome at 90 days (mRS 0-2) (OR 3.89, 95% CI 1.09–13.86, p=0.036). Changing treatment to ticagrelor in clopidogrel non-responders after emergent carotid stenting was associated with a higher rate of favorable 90-day outcomes compared to clopidogrel responders (82% vs 57%; OR 3.89, 95% CI 1.09-13.86; p=0.036).
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