Residual early neurological deterioration following dual antiplatelet in stroke: post hoc analysis of the ATAMIS trial

Background: A clinically significant proportion of patients experience early neurological deterioration (END) despite receiving dual antiplatelet therapy (DAPT) for acute ischemic stroke. It is crucial to identify this specific population for risk stratification and targeted intervention. Objectives: To identify predictors for END after DAPT in acute ischemic stroke. Design: We performed a post hoc analysis of the antiplatelet therapy in acute mild to moderate ischemic stroke (ATAMIS) trial. Methods: Patients who received DAPT (clopidogrel plus aspirin) in the ATAMIS trial were included, and classified into END and Non-END groups according to whether they experienced END. END was defined as an increase of ⩾2 points within 7 days from baseline on the National Institutes of Health Stroke Scale (NIHSS). Independent predictors were identified using multivariable logistic regression. Results: Of the 1,122 patients with acute mild-to-moderate ischemic stroke treated with DAPT, 66 (5.9%) developed END within 7 days. Multivariable analysis identified three independent factors associated with increased END risk: a shorter time from symptom onset to antiplatelet initiation (adjusted odds ratio aOR per hour, 0.97; 95% CI, 0.95–0.99; p = 0.01), higher admission systolic blood pressure (aOR per mmHg, 1.01; 95% CI, 1.00–1.02; p = 0.047), and a stroke etiology of either small artery occlusion (aOR, 2.24; 95% CI, 1.29–3.89; p = 0.004) or cardioembolism (aOR, 28.36; 95% CI, 1.23–654.11; p = 0.04). Conclusion: Among patients with mild-to-moderate ischemic stroke receiving DAPT, key predictors of END include very early presentation, elevated systolic blood pressure at admission, and a nonlarge artery atherosclerosis etiology (small artery occlusion or cardioembolism). These findings highlight subgroups that may require intensified monitoring or adjunctive therapeutic strategies beyond standard DAPT. Trial registration: ClinicalTrials.gov Identifier: NCT02869009.