MIAMI BEACH — The triple combination of antiplatelet therapy, statins, and ACE inhibitors reduces primary stroke severity and improves outcome compared with antiplatelet monotherapy or dual drug therapy, according to preliminary findings presented by Magdy Selim, M.D., at the annual meeting of the American Academy of Neurology.
Antiplatelet therapy, statins, or ACE inhibitors can each reduce incidence and recurrence of ischemic stroke when used as monotherapy, according to findings from numerous published studies.
In addition, these agents have been shown to have independent neuroprotective effects, and data from animal studies suggest there is additional protection when the three agents are combined.
Dr. Selim and his associates retrospectively studied data that had been prospectively collected on 210 consecutive stroke patients who presented within 24 hours of stroke onset to the emergency department at Beth Israel Deaconess Medical Center in Boston, where he is an attending physician in neurology.
A total of 110 patients were taking antiplatelet therapy before presentation and were assessed further. The investigators used magnetic resonance perfusion/diffusion imaging to confirm the diagnosis of ischemic stroke and assess stroke lesion volumes in 80 of the 110 patients.
A stroke team measured clinical severity in the emergency department. The 49 participants taking antiplatelet therapy alone (45 [92%] of whom took aspirin) had a mean National Institutes of Health Stroke Scale score of 11.5. The 43 participants taking an antiplatelet agent plus a statin or ACE inhibitor (dual therapy) had a score of 8.7. The 18 participants in the triple therapy group had a mean score of 4.1.
“Triple therapy resulted in an additive reduction in clinical severity of ischemic stroke and better outcomes upon discharge,” Dr. Selim explained.
Outcome was measured indirectly—for example, a higher percentage of triple therapy patients were discharged home.
There were no significant differences between groups in age (mean 72-74 years), time-to-imaging, risk factor profile, blood pressure, or lesion volume as assessed by diffusion-weighted imaging (DWI). “The only significant difference was patients with hyperlipidemia were more likely to be taking a statin,” Dr. Selim said.
Magnetic resonance imaging showed that patients on triple therapy had significantly smaller stroke lesions, with a mean volume based on perfusion-weighted imaging (PWI) of 49.1 cc, compared with 74.6 cc with single therapy and 78.5 cc with dual therapy.
Similarly, the volume of tissue at risk, based on assessment of the PWI-DWI mismatch (the difference in lesion volume as measured by PWI and DWI) was significantly smaller in patients on triple therapy (27.4 cc), compared with 46.8 cc with single therapy and 60 cc with dual therapy.
“I want to stress these findings are preliminary and require validation in larger studies,” said Dr. Selim, who received research support from the Harvard Center for Neurodegeneration and Repair in Boston.
The mismatch between DWI assessment of volume of tissue at risk (white area in image at left) and PWI (right) was smaller in patients on triple therapy. Photos courtesy Dr. Magdy Selim
