Efficacy and Safety of Ticagrelor and Aspirin in Patients With Moderate Ischemic Stroke
An Exploratory Analysis of the THALES Randomized Clinical Trial
Wang, Yongjun ✉; Pan, Yuesong; Li, Hao; Amarenco, Pierre; Denison, Hans; Evans, Scott R.; Himmelmann, Anders; James, Stefan; Birve, Filip; Ladenvall, Per; Molina, Carlos A.; Johnston, S. Claiborne ✉; Ameriso, Sebastian [Collaborator]; Gonzalez, Leonardo [Collaborator]; THALES Steering Comm Investigators [Collaborative Organization]; Ioli, Pablo [Collaborator]; Jure, Lorena [Collaborator]; Povedano, Guillermo [Collaborator]; Bruera, Guadalupe [Collaborator]; Herrera, Gustavo [Collaborator]; J Martin Artesi, Juan [Collaborator]; A Pujol Lereis, Virginia [Collaborator]; J Estol, Conrado [Collaborator]; Gomez Schneider, Maia [Collaborator]; Pigretti, Santiago [Collaborator]; Lipovestky, Fernando [Collaborator]; C Zurru, María [Collaborator]; Davis, Stephen [Collaborator]; Wong, Andrew [Collaborator]; Wijeratne, Tissa [Collaborator]; Sabet, Arman [Collaborator]; Lee, Andrew [Collaborator]; Thijs, Vincent [Collaborator]; Lemmens, Robin [Collaborator]; Yperzeele, Laetitia [Collaborator]; Vanhooren, Geert [Collaborator]; Vanacker, Peter [Collaborator]; Vansteenkiste, Iris [Collaborator]; Maqueda, Vicky [Collaborator]; Peeters, André [Collaborator]; Hasenbroekx, Marie-Christine [Collaborator]; Van Daele, Wendy [Collaborator]; De Pauw, Adinda [Collaborator]; Oedit, Regilio [Collaborator]; De Vooght, Wouter [Collaborator]; Desfontaines, Philippe [Collaborator]; Vandermeeren, Yves [Collaborator]; DA Dracoulakis, Marianna [Collaborator]; Bazan, Rodrigo [Collaborator]; M Pontes Neto, Octavio [Collaborator]; Dc Bezerra, Daniel [Collaborator]; C Marrone, Luiz [Collaborator]; A Kowacs, Pedro [Collaborator]; Hc Moro, Carla [Collaborator]; Co Macelino, Paulo [Collaborator]; Ta Pedatella, Marco [Collaborator]; Titianova, Ekaterina [Collaborator]; Staikov, Ivan [Collaborator]; Maslarov, Dimitar [Collaborator]; Petkov, Plamen [Collaborator]; Beleva, Tanya [Collaborator]; Kralev, Borislav [Collaborator]; Sotirov, Nikolay [Collaborator]; Hristov, Dimcho [Collaborator]; M Ivanova, Rumeliya [Collaborator]; V Mihailova, Margarita [Collaborator]; M Shuaib, Ashfaq [Collaborator]; Demchuk, Andrew [Collaborator]; Beaudry, Michel [Collaborator]; R Winder, Anthony [Collaborator]; Nayar, Sumiti [Collaborator]; Zheng, Huaguang [Collaborator]; Li, Shuya [Collaborator]; Zhao, Xingquan [Collaborator]; Wen, Guoqiang [Collaborator]; Dong, Xueshuang [Collaborator]; Li, Guozhong [Collaborator]; Zhang, Zhaohui [Collaborator]; Chen, Huisheng [Collaborator]; Wang, Dong [Collaborator]; Li, Xiaohong [Collaborator]; Wu, Yuncheng [Collaborator]; Zhang, Xu [Collaborator]; Zhang, Baorong [Collaborator]; Hong, Wenke [Collaborator]; Li, Xiaogang [Collaborator]; Wang, Lijuan [Collaborator]; Liu, Li [Collaborator]; Xu, Xiaolin [Collaborator]; Wang, Peifu [Collaborator]; Zheng, Weihong [Collaborator]; Zeng, Jinsheng [Collaborator]; Wang, Yukai [Collaborator]; Jia, Yan [Collaborator]; Li, Yongqiu [Collaborator]; Hu, Bo [Collaborator]; Shen, Wei [Collaborator]; Song, Zhi [Collaborator]; Hu, Zhiping [Collaborator]; Liu, Yunhai [Collaborator]; Ke, Kaifu [Collaborator]; Geng, Deqin [Collaborator]; Zhao, Shigang [Collaborator]; Zhu, Runxiu [Collaborator]; Qu, Qiumin [Collaborator]; Zhao, Xiuli [Collaborator]; Wan, Qi [Collaborator]; Yue, Yunhua [Collaborator]; Du, Huishan [Collaborator]; Zhang, Meiyun [Collaborator]; Wang, Yan [Collaborator]; Li, Dongfang [Collaborator]; Wang, Dongyu [Collaborator]; Li, Yongqiang [Collaborator]; Xie, Xufang [Collaborator]; Yu, Tingmin [Collaborator]; Liu, Qi [Collaborator]; Yang, Mingxiu [Collaborator]; Pan, Xiaoping [Collaborator]; Xu, Lijun [Collaborator]; Xu, Deen [Collaborator]; Li, Gang [Collaborator]; Xu, Anding [Collaborator]; Roubec, Martin [Collaborator]; Geier, Petr [Collaborator]; Vaclavik, Daniel [Collaborator]; Neumann, Jiri [Collaborator]; Bednarova, Jana [Collaborator]; Mikulik, Robert [Collaborator]; Hlinovsky, David [Collaborator]; Amarenco, Pierre [Collaborator]; Cordonnier, Charlotte [Collaborator]; Sibon, Igor [Collaborator]; Arquizan, Caroline [Collaborator]; Alamowitch, Sonia [Collaborator]; Lapergue, Bertrand [Collaborator]; Olivot, Jean-Marc [Collaborator]; Raposo, Nicolas [Collaborator]; Mahagne, Marie-Hélène [Collaborator]; Touze, Emmanuel [Collaborator]; Rodier, Gilles [Collaborator]; Vannier, Stéphane [Collaborator]; Samson, Yves [Collaborator]; Obadia, Michael [Collaborator]; Ellie, Emmanuel [Collaborator]; Guillon, Benoît [Collaborator]; Timsit, Serge [Collaborator]; Bejot, Yannick [Collaborator]; Wolff, Valérie [Collaborator]; Smadja, Didier [Collaborator]; Bagan-Triquenot, Aude [Collaborator]; Garnier, Pierre [Collaborator]; Ducrocq, Xavier [Collaborator]; Reiner, Peggy [Collaborator]; Moulin, Thierry [Collaborator]; Philippeau, Frédéric [Collaborator]; Pico, Fernando [Collaborator]; Richard, Sébastien [Collaborator]; Röther, Joachim [Collaborator]; Berrouschot, Jörg [Collaborator]; Soda, Hassan [Collaborator]; Pohlmann, Carsten [Collaborator]; Terborg, Christoph [Collaborator]; G Nabavi, Darius [Collaborator]; Dziewas, Rainer [Collaborator]; Köhrmann, Martin [Collaborator]; Glahn, Jörg [Collaborator]; Marquardt, Lars [Collaborator]; Kallmünzer, Bernd [Collaborator]; Weißenborn, Karin [Collaborator]; Ks Wong, Lawrence [Collaborator]; O-Y Soo, Yannie [Collaborator]; Li, Richard [Collaborator]; C Fong, Wing [Collaborator]; H Li, Siu [Collaborator]; Cheung, Raymond [Collaborator]; K Yip, Kin [Collaborator]; Wm Fok, Joshua [Collaborator]; Yp Fu, Michael [Collaborator]; Szegedi, Norbert [Collaborator]; Pozsegovits, Krisztián [Collaborator]; Valikovics, Attila [Collaborator]; Pánczél, Gyula [Collaborator]; Rózsa, Csilla [Rózsa, Csilla (neurológia), Collaborator]; Diószeghy, Péter [Collaborator]; Csányi, Attila [Collaborator]; Kerényi, Levente [Collaborator]; Nagy, Valéria [Collaborator]; Szapáry, László [Collaborator]; Bereczki, Dániel [Bereczki, Dániel (Stroke), Collaborator] Department of Neurology
(SU / FM / C); Molnár, Sándor [Collaborator]; Timár, Gyula [Collaborator]; G Folyovich, András [Collaborator]; Sátori, Mária [Collaborator]; Vastagh, Ildikó [Collaborator]; K S, Praveen [Collaborator]; Kumar, Rajnish [Collaborator]; Prasad, Atul [Collaborator]; Sharma, Vikram [Collaborator]; Verma, Alok [Collaborator]; Basu, Indraneel [Collaborator]; Z Ansari, Abu [Collaborator]; Pamidimukkala, Vijaya [Collaborator]; Raghavendra, B S [Collaborator]; D Junewar, Vivek [Collaborator]; Singh, Sumit [Collaborator]; P Kulkarni, Advait [Collaborator]; Mv Srivastava, Padma [Collaborator]; Pramod, K [Collaborator]; G Ramteke, Sanjay [Collaborator]; Bansal, Jaideep [Collaborator]; Krishan, Kewal [Collaborator]; Kumar, Hrishikesh [Collaborator]; V Kashyap, Priyanka [Collaborator]; Tcr, Ramakrishnan [Collaborator]; R Adrasetty, Gopal [Collaborator]; Yeole, Amit [Collaborator]; B Baviskar, Rahul [Collaborator]; Agnelli, Giancarlo [Collaborator]; Toni, Danilo [Collaborator]; Ricci, Stefano [Collaborator]; Tassi, Rossana [Collaborator]; Micieli, Giuseppe [Collaborator]; Mancuso, Michelangelo [Collaborator]; Orlandi, Giovanni [Collaborator]; Chiti, Alberto [Collaborator]; Delodovici, Marialuisa [Collaborator]; Carimati, Federico [Collaborator]; De Vito, Alessandro [Collaborator]; Perini, Francesco [Collaborator]; Finocchi, Cinzia [Collaborator]; Tassinari, Tiziana [Collaborator]; Del Sette, Massimo [Collaborator]; Roveri, Luisa [Collaborator]; Zini, Andrea [Collaborator]; Bigliardi, Guido [Collaborator]; R Pezzella, Francesca [Collaborator]; Cupini, Letizia [Collaborator]; Adami, Alessandro [Collaborator]; Tomelleri, Giampaolo [Collaborator]; Zanferrari, Carla [Collaborator]; A Arauz Góngora, Angel [Collaborator]; López Ruíz, Minerva [Collaborator]; Ruíz Franco, Angelica [Collaborator]; Oj Chacon Romero, José [Collaborator]; Cruz Castillo, Fernando [Collaborator]; L Ruiz-Sandoval, Jose [Collaborator]; D López Tapia, Jesús [Collaborator]; A Castillo Vargas, Edgar [Collaborator]; F Gongora Rivera, Juan [Collaborator]; Rivera Martinez, Guillermo [Collaborator]; Villarreal Careaga, Jorge [Collaborator]; Custodio, Nilton [Collaborator]; G Pamo Reyna, Oscar [Collaborator]; A Castañeda, Cesar [Collaborator]; J Pretell, Edwin [Collaborator]; Najar, Nestor [Collaborator]; C Perez, Julio [Collaborator]; Cardoza, Luisa [Collaborator]; Chavez, Carlos [Collaborator]; Reyes, Maria [Collaborator]; Członkowska, Anna [Collaborator]; Fryze, Waldemar [Collaborator]; Sobolewski, Piotr [Collaborator]; Nowak, Ryszard [Collaborator]; Szkopek, Dorota [Collaborator]; Bąk, Zbigniew [Collaborator]; Brzozowski, Sławomir [Collaborator]; Brola, Waldemar [Collaborator]; Zalisz, Marek [Collaborator]; Rejdak, Konrad [Collaborator]; Bilik, Marta [Collaborator]; Fudala, Małgorzata [Collaborator]; Tutaj, Andrzej [Collaborator]; Lasek-Bal, Anetta [Collaborator]; Kochanowicz, Jan [Collaborator]; Karaszewski, Bartosz [Collaborator]; Berkowicz, Tomasz [Collaborator]; Zwiernik, Beata [Collaborator]; Różański, Dorota [Collaborator]; P Mejnartowicz, Jan [Collaborator]; Jurga, Szymon [Collaborator]; Rożniecki, Jacek [Collaborator]; Świat, Maciej [Collaborator]; A Bajenaru, Ovidiu [Collaborator]; A Panea, Cristina [Collaborator]; A Simu, Mihaela [Collaborator]; Balasa, Rodica [Collaborator]; L Cuciureanu, Dan [Collaborator]; O Popescu, Bogdan [Collaborator]; Sabau, Monica [Collaborator]; Roman-Filip, Corina [Collaborator]; Odnopozova, Liudmila [Collaborator]; Artyukov, Oleg [Collaborator]; Milto, Anna [Collaborator]; V Stakhovskaya, Liudmila [Collaborator]; Aksentiev, Sergei [Collaborator]; E Chuprina, Svetlana [Collaborator]; B Kuznetsova, Elena [Collaborator]; I Sholomov, Ilya [Collaborator]; Malygin, Alexander [Collaborator]; Mordvintseva, Elena [Collaborator]; Y Nilk, Rostislav [Collaborator]; Ershova, Inna [Collaborator]; Khasanova, Dina [Collaborator]; Akhmadeeva, Leila [Collaborator]; Iakupova, Aida [Collaborator]; A Drozdova, Ekaterina [Collaborator]; Tanashyan, Marine [Collaborator]; Pudov, Evgenij [Collaborator]; A Shpagina, Lybov [Collaborator]; Berns, Svetlana [Collaborator]; G Lenskaya, Liudmila [Collaborator]; Golikov, Konstantin [Collaborator]; V Kovalenko, Andrey [Collaborator]; Vasilieva, Elena [Collaborator]; Reznik, Elena [Collaborator]; Zykov, Mikhail [Collaborator]; Kovalchuk, Evgeniy [Collaborator]; Popov, Dmitry [Collaborator]; Belkin, Andrey [Collaborator]; Androfagina, Olga [Collaborator]; Lokshtanova, Tatyana [Collaborator]; V Melnikova, Elena [Collaborator]; Al-Senani, Fahmi [Collaborator]; Almansour, Nouf [Collaborator]; Alhussein, Fawaz [Collaborator]; Alkhathaami, Ali [Collaborator]; Alghamdi, Saeed [Collaborator]; Brozman, Miroslav [Collaborator]; Mikloskova, Marta [Collaborator]; Krastev, Georgi [Collaborator]; Serdahely, Vlastimil [Collaborator]; Kovacik, Michal [Collaborator]; Gurcik, Ladislav [Collaborator]; Dvorak, Miloslav [Collaborator]; Kurca, Egon [Collaborator]; Cimprichova, Andrea [Collaborator]; Kycina, Marian [Collaborator]; Zacharova, Erika [Collaborator]; Risnovsky, Richard [Collaborator]; Bae, Hee-Joon [Collaborator]; B Lee, Kyung [Collaborator]; Cho, Yong-Jin [Collaborator]; Park, Jong-Moo [Collaborator]; Kim, Joon-Tae [Collaborator]; Lee, Jun [Collaborator]; Cha, Jae-Kwan [Collaborator]; Sohn, Sung-Il [Collaborator]; Shin, Dong-Ick [Collaborator]; J Lee, Soo [Collaborator]; Lee, Byung-Chul [Collaborator]; C Choi, Jay [Collaborator]; S Park, Moo [Collaborator]; Chang, Dae-Il [Collaborator]; Rha, Joung-Ho [Collaborator]; M Sung, Sang [Collaborator]; Hwang, Yangha [Collaborator]; Molina Cateriano, Carlos [Collaborator]; Roquer González, Jaume [Collaborator]; Masjuan Vallejo, Jaime [Collaborator]; Gomis Cortina, Meritxell [Collaborator]; Moniche Álvarez, Francisco [Collaborator]; Á Gamero García, Miguel [Collaborator]; Pérez Sánchez, Soledad [Collaborator]; Purroy García, Francisco [Collaborator]; Trillo Senín, Santiago [Collaborator]; Segura Martín, Tomás [Collaborator]; Serena Leal, Joaquín [Collaborator]; Arenillas Lara, Juan [Collaborator]; Martí-Fàbregas, Joan [Collaborator]; Lago Martín, Aida [Collaborator]; Tejero Juste, Carlos [Collaborator]; Marta Moreno, Javier [Collaborator]; López Hernández, Nicolás [Collaborator]; Sjöblom, Lars [Collaborator]; C Laska, Ann [Collaborator]; Callander, Margarita [Collaborator]; Mooe, Thomas [Collaborator]; Karlsson, Jan-Erik [Collaborator]; O Romanitan, Mihaela [Collaborator]; Lindgren, Arne [Collaborator]; Ahmed, Niaz [Collaborator]; Cederin, Björn [Collaborator]; Kremer, Christine [Collaborator]; Lee, Tsong-Hai [Collaborator]; Jeng, Jiann-Shing [Collaborator]; Chen, Chih-Hung [Collaborator]; L Po, Helen [Collaborator]; Liou, Chia-Wei [Collaborator]; Lin, Huey-Juan [Collaborator]; Lin, Ruey-Tay [Collaborator]; Lin, Hsiu-Fen [Collaborator]; Lien, Li-Ming [Collaborator]; Chan, Lung [Collaborator]; Huang, Wei-Shih [Collaborator]; Huang, Wen-Yi [Collaborator]; Chen, Ta-Cheng [Collaborator]; Chen, Chin-I [Collaborator]; Chen, Po-Lin [Collaborator]; Yang, Chun-Pai [Collaborator]; Sun, Yu [Collaborator]; Charnnarong Suwanwela, Nijasri [Collaborator]; Chutinet, Aurauma [Collaborator]; Tantirittisak, Tasanee [Collaborator]; Muengtaweepongsa, Sombat [Collaborator]; Nilanont, Yongchai [Collaborator]; Tiamkao, Somsak [Collaborator]; Udommongkol, Chesda [Collaborator]; Jantararotai, Witoon [Collaborator]; Chongsuvivatwong, Tabtim [Collaborator]; Srisuwananukorn, Suwat [Collaborator]; Khaykhaew, Wasutha [Collaborator]; Paiboonpol, Supachai [Collaborator]; Limudomporn, Makorn [Collaborator]; Mayotarn, Saengduan [Collaborator]; Samintharapanya, Kanoksri [Collaborator]; Arayawichanon, Arkhom [Collaborator]; Thamangraksat, Thanoot [Collaborator]; Srimanee, Duangpol [Collaborator]; Chmyr, Galyna [Collaborator]; Tomakh, Nataliya [Collaborator]; Cherkez, Alla [Collaborator]; Moskovko, Sergii [Collaborator]; Nikonov, Vadym [Collaborator]; Shkrobot, Svitlana [Collaborator]; Shulga, Lyudmyla [Collaborator]; Hrebeniuk, Hanna [Collaborator]; Yavorska, Valentyna [Collaborator]; Lytvynenko, Nataliia [Collaborator]; Khavunka, Marta [Collaborator]; Kobets, Iryna [Collaborator]; Chemer, Nataliia [Collaborator]; Tashchuk, Ivanna [Collaborator]; Myronova, Olha [Collaborator]; H Nguyen, Thang [Collaborator]; V Vo, Tan [Collaborator]; T Tran, Thanh [Collaborator]; Tp Nguyen, Nga [Collaborator]; D Nguyen, Anh [Collaborator]; T Nguyen, Binh [Collaborator]; B Nguyen, Thang [Collaborator]; H Nguyen, Ngoc [Collaborator]; D Nguyen, Quang [Collaborator]; D Le, Nhan [Collaborator]; D Pham, Dai [Collaborator]
IMPORTANCE Prior trials of dual antiplatelet therapy excluded patients with moderate
ischemic stroke. These patients were included in the Acute Stroke or Transient Ischaemic
Attack Treated With Ticagrelor and ASA for Prevention of Stroke and Death (THALES)
trial, but results have not been reported separately, raising concerns about safety
and efficacy in this subgroup.OBJECTIVE To evaluate the efficacy and safety of ticagrelor
plus aspirin in patients with moderate ischemic stroke (National Institutes of Health
Stroke Scale [NIHSS] score of 4 to 5).DESIGN, SETTING, AND PARTICIPANTS The THALES
trial was a randomized trial conducted at 414 hospitals in 28 countries in January
2018 and December 2019. This exploratory analysis compared patients with moderate
stroke (baseline NIHSS score of 4 to 5) with patients with less severe stroke (NIHSS
score of 0 to 3). A total of 9983 patients with stroke were included in the present
analysis, after excluding 2 patients with NIHSS scores greater than 5 and 1031 patients
with transient ischemic attack. Data were analyzed from March to April 2021.INTERVENTIONS
Ticagrelor (180-mg loading dose on day 1 followed by 90 mg twice daily on days 2 to
30) or placebo within 24 hours after symptom onset. All patients received aspirin,
300 to 325 mg, on day 1 followed by aspirin, 75 to 100 mg, daily on days 2 to 30.
Patients were observed for 30 additional days.MAIN OUTCOMES AND MEASURES The primary
outcome was time to stroke or death within 30 days. The primary safety outcome was
time to severe bleeding.RESULTS In total, 3312 patients presented with moderate stroke
and 6671 presented with less severe stroke. Of those in the moderate stroke group,
1293 (39.0%) were female, and the mean (SD) age was 64.5 (10.8) years; of those in
the less severe stroke group, 2518 (37.7%) were female, and the mean (SD) age was
64.8 (11.2) years. The observed primary outcome event rate in patients with moderate
stroke was 7.6%(129 of 1671) for those in the ticagrelor group and 9.1% (150 of 1641)
for those in the placebo group (hazard ratio, 0.84; 95% CI, 0.66-1.06); the primary
outcome event rate in patients with less severe stroke was 4.7%(158 of 3359) for those
in the ticagrelor group and 5.7%(190 of 3312) for those in the placebo group (hazard
ratio, 0.82; 95% CI, 0.66-1.01) (P for interaction = .88). Severe bleeding occurred
in 8 patients (0.5%) in the ticagrelor group and in 4 patients (0.2%) in the placebo
group in those with moderate stroke compared with 16 patients (0.5%) and 3 patients
(0.1%), respectively, with less severe stroke (P for interaction = .26).CONCLUSIONS
AND RELEVANCE In this study, patients with a moderate ischemic stroke had consistent
benefit from ticagrelor plus aspirin vs aspirin alone compared with patients with
less severe ischemic stroke, with no further increase in the risk of intracranial
bleeding or other severe bleeding events.