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Tirofiban for Stroke With Nonocculded Large or Medium-Sized Vessels

Intravenous tirofiban was associated with a greater likelihood of an excellent outcome than low-dose aspirin in heterogeneous groups of patients in China with stroke of recent onset or progression of stroke symptoms and nonoccluded large and medium-sized cerebral vessels, researchers report. “The incidence of symptomatic intracranial hemorrhage was low in both groups but slightly higher with tirofiban,” the authors conclude.

Participants had any of 4 clinical presentations: ineligible for thrombolysis or thrombectomy and within 24 hours after the patient was last known to be well; progression of stroke symptoms 24 to 96 hours after onset; early neurologic deterioration after thrombolysis; or thrombolysis with no improvement at 4 to 24 hours. After randomization to intravenous tirofiban or oral aspirin 100 mg per day for 2 days (followed by oral aspirin until day 90), the changes in a primary efficacy endpoint of an excellent outcome (score of 0 or 1 on the modified Rankin scale at 90 days) were as follows: “A total of 606 patients were assigned to the tirofiban group and 571 to the aspirin group. Most patients had small infarctions that were presumed to be atherosclerotic. The percentage of patients with a score of 0 or 1 on the modified Rankin scale at 90 days was 29.1% with tirofiban and 22.2% with aspirin (adjusted risk ratio, 1.26; 95% confidence interval, 1.04 to 1.53, P = 0.02). Results for secondary endpoints were generally not consistent with the results of the primary analysis. Mortality was similar in the two groups. The incidence of symptomatic intracranial hemorrhage was 1.0% in the tirofiban group and 0% in the aspirin group.”

Editorial: “Should we start using tirofiban for patients with stroke who do not undergo thrombolysis or thrombectomy,” ask editorialists. “Although [these results] are encouraging, we should consider that other trials of tirofiban, while showing safety, had mixed efficacy results. The Safety of Tirofiban in Acute Ischemic Stroke trial and the Study of Efficacy of Tirofiban in Acute Ischemic Stroke did not show benefit of tirofiban in the context of acute stroke, whereas the Efficacy and Safety of Tirofiban in Clinical Patients with Acute Ischemic Stroke (ESCAPIST) trial showed better 90-day outcomes. These studies were smaller than the current one, and their participants had relatively milder stroke severity. Nevertheless, in the RESCUE BT2 trial, most patients (73%) had small deep infarcts, and there was a high prevalence of intracranial arterial narrowing (48%), presumably atherosclerotic, which may limit the generalizability of the trial results to non-Chinese populations.”

Source: New England Journal of Medicine