Can Tirofiban Improve the Outcome of Patients With Acute Ischemic Stroke: A Propensity Score Matching Analysis

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Can Tirofiban Improve the Outcome of Patients With Acute Ischemic Stroke: A Propensity Score Matching Analysis

 

Lingxin Cai¹, Xiaobo Yu¹, Jun Yu¹, Jing Xu¹, Liang Xu¹, Chenhan Ling¹, Min Lou², Cheng Yu^3* and Cong Qian^1*

• ¹Department of Neurological Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
• ²Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
• ³Department of Neurosurgery, The Second People's Hospital, Quzhou, China

Objective: To evaluate the efficacy and safety of tirofiban for patients with acute ischemic stroke (AIS), especially posterior circulation stroke (PCS).

Methods: We enrolled consecutive patients with AIS who suffered large artery occlusion (LAO) and underwent mechanical thrombectomy (MT) between January 2016 and May 2020. Patients were divided into two groups according to whether tirofiban was used during MT. The primary efficacy outcome was a favorable functional outcome, defined as a modified Rankin Scale (mRS) score of 0–2 at 3 months. The safety outcomes were the rate of mortality at 3 months and the presence of intracranial hemorrhage (ICH) and symptomatic intracranial hemorrhage (sICH). Cohorts were balanced using 1:1 propensity score matching (PSM). Subgroup analysis was further performed to compare the efficacy and safety of tirofiban between the anterior circulation stroke (ACS) and PCS groups.

Results: A total of 292 patients were eligible for this study and divided into the tirofiban group (n = 51) and the no-tirofiban group (n = 241). In the propensity-score-matched cohort, the tirofiban group had a higher rate of favorable outcomes than the no-tirofiban group (49.0 vs. 25.5%, p = 0.014), and the mortality at 3 months showed a greater downward trend in the tirofiban group than the no-tirofiban group (15.6 vs. 33.3% p = 0.064). The risk of sICH and ICH was the same between the tirofiban and control groups (17.6 vs. 27.4% p = 0.236, 31.3 vs. 45.1% p = 0.154, respectively). Tirofiban use was predictive of favorable outcomes [adjusted odds ratio (aOR) = 2.87, 95% confidence interval (CI) 1.52–6.44, p = 0.043] after multiple logistic regression analysis. Subgroup analysis revealed that tirofiban use was significantly associated with favorable outcomes in ACS (aOR = 3.66, 95% CI 1.24–5.22, p = 0.019) but not in PCS (aOR = 1.12, 95% CI 0.47–7.52, p = 0.570).

Conclusion: We demonstrated that tirofiban may be associated with improving favorable outcome for the AIS patients who underwent MT, without increasing ICH or sICH. Furthermore, our results indicated that for PCS patients tirofiban may not be associated with favorable outcome, and more comprehensive randomized controlled trials are needed to confirm this finding.

Introduction

A number of randomized clinical trials have shown the benefit of mechanical thrombectomy (MT) in the treatment of acute ischemic stroke (AIS) that is due to large-vessel occlusion (LVO) (1, 2). However, this endovascular recanalization approach may lead to endothelial injury, plaque rupture, and subsequent platelet activation, leading to early re-occlusion and poor prognosis. Tirofiban is a non-peptide selective glycoprotein (GP) IIb/IIIa receptor inhibitor that reversibly inhibits fibrinogen-dependent platelet aggregation and subsequent formation of thrombi, which contribute to the major atherosclerotic complications in the progression of AIS (3).

Clinical trials in patients with AIS initially demonstrated the safety and efficacy of tirofiban as an adjunct to MT for AIS patients. However, the results of these trials have been controversial; some studies have shown that tirofiban does not improve prognosis and may even increase intracranial hemorrhage (ICH) and mortality. Therefore, more data are needed to confirm further the benefits and risks of tirofiban. A series of follow-up studies have reported a number of clinically valuable findings about the tirofiban regimen following MT, including the specific dose (4), injection method (5), and patient selection according to etiology (6). However, the specific indications and patient selection are still under debate. Considering the different clinical characteristics of posterior circulation stroke (PCS) and anterior circulation stroke (ACS) (7), as well as the different postoperative prognoses of patients with MT between the two groups (8), there is a hypothesis that tirofiban may have inconsistent risks and benefits in PCS and ACS. At present, there are some studies about the benefit of MT in PCS patients and the administration of tirofiban following MT (9, 10), but there are few studies exploring tirofiban in patients with PCS.

The main aim of this study was to test the safety and efficacy of tirofiban following MT in AIS patients. Propensity score matching (PSM) was used to match tirofiban- and no-tirofiban-treated patients for potential confounders. Regression analysis after PSM was performed to identify independent associations with the outcomes. The secondary aims were to compare the risks and benefits of tirofiban following MT between PCS and ACS.

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