No improvement in disability seen in patients treated with tirofiban prior to endovascular thrombectomy

Data from the randomized, double-blind, placebo-controlled RESCUE-BT trial showed that adding intravenous tirofiban before endovascular thrombectomy (EVT) had no impact on severity of disability in people who have had an acute ischemic stroke with great vessel occlusion (LVO). Therefore, the researchers concluded that the results do not support the use of tirofiban before VTE for the treatment of acute ischemic stroke.1

The study included 948 participants who received either tirofiban (n=463), a highly selective non-peptide glycoprotein 2b/3a receptor antagonist, or placebo (n=485) before undergoing VTE. All patients completed the trial, with modified Rankin Scale (mRS) scores of 3 (IQR, 1-4) and 3 (IQR, 1-4) recorded in the tirofiban and placebo groups, respectively. The adjusted pooled odds ratio (OR) for a favorable change to a lower mRS score at 90 days comparing tirofiban to placebo was 1.08 (95% CI, 0.86-1.36; P = .50).

In an analysis by stroke etiology, there was a more favorable point estimate for tirofiban in the large artery atherosclerosis subgroup, but not in the other artery atherosclerosis subgroup; however, the results of the indication test were not statistically significant (joint OR adjusted for less disability, 1.40 [95% CI, 1.00-1.97]; against 0.84 [95% CI, 0.62-1.15]; P = 0.09).

“These results do not support the routine use of intravenous tirofiban as an adjunct to thrombectomy within a ‘late’ time window (beyond the recommended use of thrombolysis therapy within 4.5 hours of onset of thrombectomy). symptoms) after acute ischemic stroke,” Craig S. Anderson, MD, PhD, Professor of Neurology, UNSW Syndey, wrote in a related editorial.2 “Since any delay in onset of symptoms relative to treatment time reduces the likelihood of a good outcome from great vessel occlusion, it is reassuring that both randomized groups achieved high rates of recanalization ( >90%) with single-pass application of a range of approaches Any modest potential benefit of tirofiban in the atherosclerosis of the large arteries subgroup was outweighed by the overall risk of serious bleeding as a complication unique major of thrombectomy.

READ MORE: Trends in stroke incidence at younger ages call for re-examination of causes and methods of prevention

Previous studies have shown that tirofiban may reduce the risk of thrombotic complications during percutaneous coronary intervention; however, most of the data evaluating the agent as an adjunctive therapy in OLV stroke are inconsistent. Until RESCUE-BT, no randomized trial had assessed the role of tirofiban in EVT of acute ischemic stroke. In this investigator-initiated trial, patients had National Institutes of Health Stroke Scale scores of 30 or less, an Alberta Stroke Program Early CT score of 6 or greater, and an occlusion of the intracranial carotid artery or the first or second segment of the middle cerebral artery. .

There were several secondary technical efficacy outcomes, including substantial reperfusion on initial DSA before EVT, substantial reperfusion on final angiogram, use of rescue medication, recanalization on follow-up CTA or MRA within 48 hours, as well as secondary safety criteria such as any radiological examination. intracranial hemorrhage or 90-day mortality. For the 6 secondary clinical efficacy outcomes, no statistically significant differences were observed. For example, 36.3% of the tirofiban group and 32.4% of those on placebo had no disability or returned to their premorbid mRS score (difference, 3.9% [95% CI, –2.1% to 10%]; Adjusted OR, 1.21 [95% CI, 0.91-1.62]).

Although no significant difference was detected in the incidence of symptomatic intracranial hemorrhage between the groups, those in the tirofiban group had a higher rate of radiological intracranial hemorrhage (34.9% versus 28.0% [95% CI, 1.0-12.8]; OR adjusted, 1.40 [95% CI, 1.06-1.86]; P = .02). In addition, 90-day mortality was 18.1% with tirofiban and 16.9% with placebo (difference of 1.2% [95% CI, –3.6 to 6.1]; Adjusted OR, 1.09 [95% CI, 0.77-1.55]; P = 0.63).

REFERENCES
1. RESCUE-BT trial investigators. Effect of intravenous tirofiban versus placebo before endovascular thrombectomy on functional outcomes in stroke by great vessel occlusion: the RESCUE-BT randomized clinical trial. JAMA Neurol. 2022;328(6):543-553. doi:10.1001/jama.2022.12584
2. Anderson CS, Song L, Liu J. Therapeutic strategies for intracranial atherosclerosis. JAMA Neurol. 2022;328(6):529-531. doi:10.1001/jama.2022.11525.

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