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Abstract
Background and Objective Genotype data of the Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE) trial showed that efficacy of clopidogrel aspirin depended on CYP2C19 genotype and risk profile. A stratification of patients who carried CYP2C19 loss-of-function (LOF) alleles according to the risk of recurrent stroke may be important for selecting optimal antiplatelet therapy. We aimed to compare the efficacy and safety of ticagrelor aspirin with clopidogrel aspirin in CYP2C19 LOF carriers with minor stroke or transient ischemic attack (TIA) stratified by risk profile.
Methods Data were obtained from Ticagrelor or Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II (CHANCE-2) trial. Low-risk and high-risk profiles were defined by Essen Stroke Risk Score (ESRS) (<3 [low risk] and ≥3 [high risk], respectively).
Results A total of 6,412 CYP2C19 LOF carriers were enrolled; ticagrelor aspirin was associated with a reduced risk of primary outcome (new stroke within 90-day follow-up) in patients at low risk (hazard ratio [HR], 0.65; 95% CI, 0.48–0.82), but not in those at high risk (HR, 0.97; 95% CI, 0.73–1.29), compared with clopidogrel aspirin (p = 0.02 for interaction). Secondary outcomes generally went in the same direction as the primary outcome. The primary safety outcome of severe or moderate bleeding did not differ based on risk profile (p = 0.24 for interaction), although the incidence of total bleeding was greater with ticagrelor aspirin than with clopidogrel aspirin among patients at low risk (p < 0.01 for interaction). Analysis in the per-protocol population yielded similar results.
Discussion This post hoc analysis of CHANCE-2 trial showed that CYP2C19 LOF carriers with minor stroke or TIA at low risk of recurrent stroke received a greater benefit from ticagrelor aspirin than from clopidogrel aspirin.
Classification of Evidence This study provides Class II evidence that CYP2C19 LOF carriers with minor stroke or TIA at low risk, but not at high risk, of recurrent stroke (by the ESRS) received a greater benefit from ticagrelor aspirin than from clopidogrel aspirin.
Trial Registration Information URL: www.clinicaltrials.gov. Unique identifier: NCT04078737.
Glossary
- CAPRIE=
- Clopidogrel vs Aspirin in Patients at Risk of Ischemic Events;
- CHANCE=
- Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack;
- CHANCE-2=
- Clopidogrel with Aspirin in High-Risk Patients with Acute Nondisabling Cerebrovascular Events II;
- CYP=
- cytochrome p450;
- ESRS=
- Essen Stroke Risk Score;
- GUSTO=
- Global Utilization of Streptokinase and Tissue plasminogen activator for Occluded coronary arteries;
- HR=
- hazard ratio;
- LOF=
- loss of function;
- REACH=
- REduction of Atherothrombosis for Continued Health;
- TIA=
- transient ischemic attack
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Submitted and externally peer reviewed. The handling editor was Editor-in-Chief José Merino, MD, MPhil, FAAN.
↵* A. Wang and X. Meng contributed equally to this work.
Editorial, page 223
Class of Evidence: NPub.org/coe
CME Course: NPub.org/cmelist
- Received May 4, 2022.
- Accepted in final form September 8, 2022.
- © 2022 American Academy of Neurology
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