Tirofiban drip limits neurologic decline in acute ischaemic stroke patients

Treatment with intravenous (IV) tirofiban helps curb the risk of early neurologic deterioration when administered within 24 hours of acute ischaemic stroke onset, according to the TREND trial.

Compared with patients who received oral aspirin, those who received IV tirofiban were less likely to show at least a 4-point increase in National Institutes of Health Stroke Scale (NIHSS) score in the first 72 hours (4.2 percent vs 13.2 percent; relative risk [RR], 0.32, 95 percent confidence interval [CI], 0.16–0.65). This reduced early neurologic deterioration benefit with tirofiban was consistently observed across multiple subgroups. [ISC 2024, abstract LB28]

The secondary endpoint of neurologic deterioration, defined by an NIHSS score of ≥2, also favoured tirofiban (11.7 percent vs 23.6 percent; RR, 0.49, 95 percent CI, 0.32–0.75).

In terms of 90-day outcomes, the proportion of patients who achieved an excellent or a good outcome on the modified Rankin Scale (mRS) disability score did not significantly differ between the IV tirofiban and oral aspirin groups (mRS, 0-1: 75 percent vs 68 percent, respectively; mRS, 0-2: 89 percent vs 86 percent, respectively).

“This trial has shown that tirofiban effectively prevents neurological deterioration in these patients despite the absence of significant differences in excellent 90-day outcomes, a modified Rankin Score of 0-1, due to the small sample size,” said primary investigator Dr Wenbo Zhao of Xuanwu Hospital, Capital Medical University in Beijing, China, in a news release.

Beyond the positive data for tirofiban in acute ischaemic stroke patients in previous trials, Zhao highlighted the suitability of the drug in those with dysphagia, a common complication of stroke. The IV antiplatelet agent offers a convenient alternative to oral medications, which might be difficult to swallow, he said.

No increase in bleeding risk

Conducted across multiple stroke centres in China, TREND included 426 patients (median age 64 years, 29 percent women) with an acute noncardioembolic ischaemic stroke, with the median time from symptom onset being 10‒12 hours. These patients had a neurologic deficit attributed to focal cerebral ischaemia, had an NIHSS score of between 4 and 20 (median 5), and had not undergone IV thrombolysis treatment or endovascular thrombectomy.

The patients were randomly assigned to receive either IV tirofiban (n=214) or oral aspirin (n=212) for 72 hours, with the treatment administered within 24 hours of stroke onset. Following the initial treatment, all patients continued receiving antiplatelet medications orally.

Safety data showed no cases of symptomatic intracerebral haemorrhage within 72 hours after randomization in either group, with similar rates of systemic bleeding. Mild bleeding occurred in 6.6 percent of patients in the tirofiban group and in 5.1 percent of those in the aspirin group (p=0.33), while severe bleeding did not occur in any of the patients.

“The remarkable efficacy of tirofiban in preventing neurological deterioration surpassed our initial predictions. However, the incidence of neurological deterioration in the control group and the incidence of intracerebral haemorrhage in this study population are much lower than we expected, which could be attributed to the relatively minor neurological impairments observed in our study population,” Zhao noted.

“In future clinical practice, particularly in East Asian countries like China, physicians would be inclined to utilize IV tirofiban during the acute phase of ischaemic stroke to prevent neurological deterioration. This approach may enhance patients’ adherence to treatment and foster stronger trust between patients and doctors,” he added.

Zhao shared that a follow-up trial of IV tirofiban following IV thrombolysis to improve functional outcomes by way of reducing neurologic deterioration is in the works.