Tirofiban Versus Alteplase for Patients With Minor Acute Ischemic Stroke: A Target Trial Emulation Study

Background Tirofiban has emerged as a potential treatment for acute ischemic stroke. We aimed to evaluate the efficacy and safety of tirofiban in patients with minor stroke within 4.5 hours of symptom onset. Methods We emulated a target trial using observational data. Patients with minor stroke (National Institutes of Health Stroke Scale score ≤5) who received tirofiban or alteplase within 4.5 hours were included. The primary outcome was excellent functional outcome (modified Rankin Scale score 0–1) at 90 days. Secondary outcomes included modified Rankin Scale score of 0 to 2 at 90 days, 24‐hour National Institutes of Health Stroke Scale changes, ordinal shift in modified Rankin Scale, and early neurological deterioration or improvement. Safety outcomes included symptomatic intracranial hemorrhage, intracranial hemorrhage, any bleeding, and 90‐day all‐cause death. Results Of 677 eligible patients, 369 received tirofiban and 308 received alteplase. There was no significant difference in 90‐day modified Rankin Scale score of 0 to 1 between groups (risk ratio, 1.06 95% CI, 0.97–1.16; P =0.20). Tirofiban was associated with lower risks of neurological deterioration at 24 hours (risk ratio, 0.31 95% CI, 0.16–0.59; P <0.001), intracranial hemorrhage (risk ratio, 0.06 95% CI, 0.01–0.46; P =0.007), and any bleeding (risk ratio, 0.13 95% CI, 0.06–0.30; P <0.001). No symptomatic intracranial hemorrhage occurred in the tirofiban group. Ninety‐day all‐cause death did not differ significantly. Conclusions In minor acute ischemic stroke treated within 4.5 hours, intravenous tirofiban showed no significant difference in 90‐day functional outcomes relative to alteplase and was associated with lower risks of early neurological deterioration and bleeding, suggesting it could be considered a potential treatment option pending further randomized trials. Registration URL: https://www.chictr.org.cn ; Unique Identifier: ChiCTR2500106107.