Ticagrelor for stroke prevention in patients with vascular risk factors

A systematic review and meta-analysis

Konark Malhotra, Nitin Goyal, Alissa S. Kasunich, Sunil A. Sheth, Aristeidis H. Katsanos, Andrei Alexandrov, Georgios Tsivgoulis

Research output: Contribution to journalArticle

5 Citations (Scopus)

Abstract

Background: Even though ticagrelor was beneficial in prior cardiovascular trials, its efficacy in stroke prevention was inconclusive in recent randomized-controlled clinical trials (RCTs). We sought to consolidate the evidence for efficacy and safety of ticagrelor for stroke prevention. Methods: We conducted a systematic review and meta-analysis of RCTs in major databases reporting following efficacy and safety outcomes among patients with cerebral or cardiovascular risk factors treated with ticagrelor (vs. control): ischemic stroke (IS), combined ischemic and hemorrhagic stroke, myocardial infarction (MI), cardiovascular death (CVD), all-cause mortality, and major bleeding events. We pooled risk ratios (RR) and adjusted hazard ratios (HR adjusted ) from each trial using random-effect models, and assessed the heterogeneity using Cochran Q and I 2 statistics. Results: We identified 13 RCTs, comprising 64,360 patients. In comparison to control group, ticagrelor reduced the risk of IS (RR = 0.86; 95%CI = 0.78–0.95, p =.003; I 2 = 0%), combined ischemic and hemorrhagic strokes (risk ratio: 0.90; 95%CI: 0.81–1.00, p =.05; I 2 = 0%), and composite stroke/MI/CVD (RR = 0.90; 95%CI = 0.81–0.99, p =.03; I 2 = 47%). Ticagrelor was not associated with increased risk of mortality (RR: 0.95; 95%CI: 0.84–1.07; p =.40) or major bleeding events (RR: 1.18; 95%CI: 0.92–1.50; p =.19). Additional analyses demonstrated that ticagrelor reduced the risk of incident strokes (HR adjusted = 0.87; 95%CI = 0.76–0.98; p =.03) and composite stroke/MI/CVD (HR adjusted = 0.88; 95%CI = 0.78–0.98; p =.02) among patients with prior history of IS or transient ischemic attack. Conclusions: Ticagrelor seems to be a beneficial option for primary and secondary stroke prevention in patients with cerebral or cardiovascular risk factors. Further RCTs are needed to evaluate the role of ticagrelor in secondary stroke prevention.

Original languageEnglish (US)
Pages (from-to)212-218
Number of pages7
JournalJournal of the Neurological Sciences
Volume390
DOIs
StatePublished - Jul 15 2018

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Meta-Analysis
Stroke
Odds Ratio
Randomized Controlled Trials
Myocardial Infarction
Secondary Prevention
Ticagrelor
vascular factor
Hemorrhage
Safety
Mortality
Transient Ischemic Attack
Cause of Death
Databases
Control Groups

All Science Journal Classification (ASJC) codes

  • Neurology
  • Clinical Neurology

Cite this

Ticagrelor for stroke prevention in patients with vascular risk factors : A systematic review and meta-analysis. / Malhotra, Konark; Goyal, Nitin; Kasunich, Alissa S.; Sheth, Sunil A.; Katsanos, Aristeidis H.; Alexandrov, Andrei; Tsivgoulis, Georgios.

In: Journal of the Neurological Sciences, Vol. 390, 15.07.2018, p. 212-218.

Research output: Contribution to journalArticle

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T1 - Ticagrelor for stroke prevention in patients with vascular risk factors

T2 - A systematic review and meta-analysis

AU - Malhotra, Konark

AU - Goyal, Nitin

AU - Kasunich, Alissa S.

AU - Sheth, Sunil A.

AU - Katsanos, Aristeidis H.

AU - Alexandrov, Andrei

AU - Tsivgoulis, Georgios

PY - 2018/7/15

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N2 - Background: Even though ticagrelor was beneficial in prior cardiovascular trials, its efficacy in stroke prevention was inconclusive in recent randomized-controlled clinical trials (RCTs). We sought to consolidate the evidence for efficacy and safety of ticagrelor for stroke prevention. Methods: We conducted a systematic review and meta-analysis of RCTs in major databases reporting following efficacy and safety outcomes among patients with cerebral or cardiovascular risk factors treated with ticagrelor (vs. control): ischemic stroke (IS), combined ischemic and hemorrhagic stroke, myocardial infarction (MI), cardiovascular death (CVD), all-cause mortality, and major bleeding events. We pooled risk ratios (RR) and adjusted hazard ratios (HR adjusted ) from each trial using random-effect models, and assessed the heterogeneity using Cochran Q and I 2 statistics. Results: We identified 13 RCTs, comprising 64,360 patients. In comparison to control group, ticagrelor reduced the risk of IS (RR = 0.86; 95%CI = 0.78–0.95, p =.003; I 2 = 0%), combined ischemic and hemorrhagic strokes (risk ratio: 0.90; 95%CI: 0.81–1.00, p =.05; I 2 = 0%), and composite stroke/MI/CVD (RR = 0.90; 95%CI = 0.81–0.99, p =.03; I 2 = 47%). Ticagrelor was not associated with increased risk of mortality (RR: 0.95; 95%CI: 0.84–1.07; p =.40) or major bleeding events (RR: 1.18; 95%CI: 0.92–1.50; p =.19). Additional analyses demonstrated that ticagrelor reduced the risk of incident strokes (HR adjusted = 0.87; 95%CI = 0.76–0.98; p =.03) and composite stroke/MI/CVD (HR adjusted = 0.88; 95%CI = 0.78–0.98; p =.02) among patients with prior history of IS or transient ischemic attack. Conclusions: Ticagrelor seems to be a beneficial option for primary and secondary stroke prevention in patients with cerebral or cardiovascular risk factors. Further RCTs are needed to evaluate the role of ticagrelor in secondary stroke prevention.

AB - Background: Even though ticagrelor was beneficial in prior cardiovascular trials, its efficacy in stroke prevention was inconclusive in recent randomized-controlled clinical trials (RCTs). We sought to consolidate the evidence for efficacy and safety of ticagrelor for stroke prevention. Methods: We conducted a systematic review and meta-analysis of RCTs in major databases reporting following efficacy and safety outcomes among patients with cerebral or cardiovascular risk factors treated with ticagrelor (vs. control): ischemic stroke (IS), combined ischemic and hemorrhagic stroke, myocardial infarction (MI), cardiovascular death (CVD), all-cause mortality, and major bleeding events. We pooled risk ratios (RR) and adjusted hazard ratios (HR adjusted ) from each trial using random-effect models, and assessed the heterogeneity using Cochran Q and I 2 statistics. Results: We identified 13 RCTs, comprising 64,360 patients. In comparison to control group, ticagrelor reduced the risk of IS (RR = 0.86; 95%CI = 0.78–0.95, p =.003; I 2 = 0%), combined ischemic and hemorrhagic strokes (risk ratio: 0.90; 95%CI: 0.81–1.00, p =.05; I 2 = 0%), and composite stroke/MI/CVD (RR = 0.90; 95%CI = 0.81–0.99, p =.03; I 2 = 47%). Ticagrelor was not associated with increased risk of mortality (RR: 0.95; 95%CI: 0.84–1.07; p =.40) or major bleeding events (RR: 1.18; 95%CI: 0.92–1.50; p =.19). Additional analyses demonstrated that ticagrelor reduced the risk of incident strokes (HR adjusted = 0.87; 95%CI = 0.76–0.98; p =.03) and composite stroke/MI/CVD (HR adjusted = 0.88; 95%CI = 0.78–0.98; p =.02) among patients with prior history of IS or transient ischemic attack. Conclusions: Ticagrelor seems to be a beneficial option for primary and secondary stroke prevention in patients with cerebral or cardiovascular risk factors. Further RCTs are needed to evaluate the role of ticagrelor in secondary stroke prevention.

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