1. In this randomized controlled trial, tirofiban was associated with better outcomes than low-dose aspirin for patients with stroke without large or medium-sized vessel occlusion.
2. For patients with recent onset stroke or progression of stroke symptoms, tirofiban showed a slightly higher incidence of intracranial hemorrhage as compared with low-dose aspirin.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Many currently available therapies may not be appropriate for patients with stroke without occlusion of large or medium-sized arteries. For example, these patients may be ineligible for intravenous or endovascular reperfusion therapy. Tirofiban has been proposed to be a glycoprotein IIb/IIIa receptor inhibitor that can treat patients with stroke. However, there is a knowledge gap in understanding the effectiveness of tirofiban compared with aspirin in patients without large or medium-sized vessel occlusion presenting with stroke symptoms. Overall, this study found that for patients with acute ischemic stroke without large/medium-sized vessel occlusion, intravenous tirofiban resulted in a greater likelihood of an excellent outcome at 90 days than oral aspirin. This study was limited by patient presentation varying, as well as a small proportion of enrolled patients being treated with intravenous (IV) thrombolysis. Nevertheless, these study’s findings are significant, as they demonstrate that IV tirofiban may be more effective than low-dose aspirin, resulting in a better outcome for patients with acute stroke without large or medium-sized vessel occlusion.
Click to read the study in NEJM
Relevant Reading: Comparison of Early Invasive and Conservative Strategies in Patients with Unstable Coronary Syndromes Treated with the Glycoprotein IIb/IIIa Inhibitor Tirofiban
In-Depth [randomized controlled trial]: This double-blinded, randomized controlled trial included patients who had an acute ischemic stroke without occlusion of large or medium-sized vessels in China. Patients were randomized to receive either tirofiban (n=606) or low-dose aspirin (n=571) for two days following the event, then all received aspirin for another 88 days. The primary outcome measured was an excellent outcome, defined as a score of zero or one on the modified Rankin scale (an ordinal global disability scale with scores ranging from 0 [no symptoms] to 6 [death]) at 90 days after randomization. Outcomes in the primary analysis were assessed via a modified intention-to-treat population, with a Poisson regression model with robust error estimation. Based on the primary analysis, the percentage of patients with a score of zero or one 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). Mortality was similar between the two groups, though the incidence of symptomatic intracranial hemorrhage was 1.0% in the tirofiban group and 0% in the aspirin group. In summary, this study demonstrates that intravenous tirofiban is associated with a greater likelihood of an excellent outcome in patients with acute ischemic stroke as compared to low-dose aspirin.
Image: PD
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