Background: Even though ticagrelor was beneficial in prior cardiovascular trials, its efficacy in stroke prevention was inconclusive in recent randomized-controlled clinical trials (RCTs). We sought to consolidate the evidence for efficacy and safety of ticagrelor for stroke prevention.
Methods: We conducted a systematic review and meta-analysis of RCTs in major databases reporting following efficacy and safety outcomes among patients with cerebral or cardiovascular risk factors treated with ticagrelor (vs. control): ischemic stroke (IS), combined ischemic and hemorrhagic stroke, myocardial infarction (MI), cardiovascular death (CVD), all-cause mortality, and major bleeding events. We pooled risk ratios (RR) and adjusted hazard ratios (HRadjusted) from each trial using random-effect models, and assessed the heterogeneity using Cochran Q and I2 statistics.
Results: We identified 13 RCTs, comprising 64,360 patients. In comparison to control group, ticagrelor reduced the risk of IS (RR = 0.86; 95%CI = 0.78-0.95, p = .003; I2 = 0%), combined ischemic and hemorrhagic strokes (risk ratio: 0.90; 95%CI: 0.81-1.00, p = .05; I2 = 0%), and composite stroke/MI/CVD (RR = 0.90; 95%CI = 0.81-0.99, p = .03; I2 = 47%). Ticagrelor was not associated with increased risk of mortality (RR: 0.95; 95%CI: 0.84-1.07; p = .40) or major bleeding events (RR: 1.18; 95%CI: 0.92-1.50; p = .19). Additional analyses demonstrated that ticagrelor reduced the risk of incident strokes (HRadjusted = 0.87; 95%CI = 0.76-0.98; p = .03) and composite stroke/MI/CVD (HRadjusted = 0.88; 95%CI = 0.78-0.98; p = .02) among patients with prior history of IS or transient ischemic attack.
Conclusions: Ticagrelor seems to be a beneficial option for primary and secondary stroke prevention in patients with cerebral or cardiovascular risk factors. Further RCTs are needed to evaluate the role of ticagrelor in secondary stroke prevention.
Keywords: Ischemic stroke; Secondary prevention; Ticagrelor; Vascular.
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