Evolving Approaches to Antithrombotics in Stroke Prevention and Treatment

Vijayakumar Javalkar, MD, MCh; Okkes Kuybu, MD; Abdallah Amireh, MD; Roger E. Kelley, MD


South Med J. 2020;113(11):585-592. 

In This Article

Ticagrelor for Secondary Stroke Prevention

The SOCRATES (Acute Stroke or Transient Ischemic Attack Treated with Aspirin or Ticagrelor and Patient Outcomes) trial[54] compared aspirin with ticagrelor in acute noncardioembolic stroke or TIA. The primary endpoint was the time to the occurrence of stroke, MI, or death within 90 days. Minor strokes (ie, National Institutes of Health Stroke Scale score <5) or high-risk TIA patients (ie, an ABCD2 score >4), or symptomatic intracranial or extracranial arterial stenosis were included. The dose of ticagrelor was a loading dose of 180 mg on day 1 followed by 90 mg twice daily for days 2 through 90. The dose of aspirin was 300 mg on day 1 followed by 100 mg/day for days 2 through 90. The primary composite endpoint occurred in 6.7% in the ticagrelor group and 7.5% in the aspirin group (HR 0.89, 95% CI 0.78–1.01, P = 0.07). The main secondary endpoint, ischemic stroke, occurred in 5.8% in the ticagrelor group and 6.7% in the aspirin group (HR 0.87, 95% CI 0.76–1.00, P = 0.046).

There was a trend in benefit for ticagrelor in minor stroke or higher-risk TIA, with no significant difference in the major safety outcomes. Dyspnea was the major reason for the discontinuation of ticagrelor. A subgroup analysis of the SOCRATES trial[55] reported that ticagrelor was superior to aspirin at preventing stroke, MI, or death at 90 days in patients with minor stroke or high-risk TIA when associated with ipsilateral atherosclerotic stenosis.