Comparative effectiveness of reduced dose Ticagrelor, full dose Ticagrelor, and Clopidogrel in acute stroke management.

BACKGROUND AND PURPOSE: Ticagrelor use is increasing in acute ischemic stroke and transient ischemic attack management, but optimal dosing is unclear. We aimed to compare the effectiveness and safety of reduced-dose ticagrelor (45/60 mg BID), full-dose ticagrelor (90 mg BID), and clopidogrel (75 mg daily) for secondary stroke prevention.

METHODS

This retrospective cohort study analyzed patients with acute ischemic stroke or transient ischemic attack treated at a single comprehensive stroke center between September 1, 2020, and July 1, 2022. Primary outcomes were 90-day mortality and 90-day functional independence (modified Rankin Scale 0-2). Baseline covariates associated with treatment assignment were selected via elastic net regression to generate propensity scores. Treatment groups (any ticagrelor vs. clopidogrel; reduced- vs. full-dose ticagrelor) were compared using inverse probability weighting adjustment.

RESULTS

The study included 562 patients (mean age 66.3 ± 12.9 years; 52.3 % female). Using inverse probability weighting-adjusted analyses comparing any ticagrelor dose to clopidogrel (N = 363), ticagrelor was associated with significantly lower odds of 90-day mortality (Odds Ratio 0.51, 95 % Confidence Interval 0.28-0.93, p = 0.03). No significant difference was observed for 90-day functional independence between ticagrelor and clopidogrel (Odds Ratio 0.64, 95 % Confidence Interval 0.33-1.24, p = 0.18). When comparing reduced-dose versus full-dose ticagrelor (N = 72), no significant differences were found for 90-day mortality or 90-day functional independence.

CONCLUSIONS

Ticagrelor use was associated with lower 90-day mortality compared to clopidogrel after acute ischemic attack or transient ischemic attack. Reduced-dose ticagrelor demonstrated comparable effectiveness to full-dose ticagrelor. These findings together suggest that reduced-dose ticagrelor may be explored as a viable alternative in future larger prospective studies.