The Value Of Platelet Reactivity Test In Acute Ischemic Stroke Patients

Part 1: Risk factors of High on-treatment platelet reactivity in patients with acute ischemic strokeObjective: Antiplatelet aggregation therapy is important for both treatment in acute period and secondary prevention of ischemic stroke.However,the platelet reactivity to antiplatelet drugs varies widely in clinical practice.Currently,there are limited studies exploring the risk factors of platelet reactivity to antiplatelet drugs in patients with ischemic stroke.Therefore,we aim to find the risk factors associated with the efficacy of antiplatelet drugs,in order to provide guidance for clinical treatment decisions.Methods: Acute ischemic stroke patients who were treated with aspirin and clopidogrel were consecutively included.Platelet reactivity was assessed by thromboelastography and the rate of platelet inhibition induced by arachidonic acid(AA)or adenosine diphosphate(ADP)was used to define the high on-treatment platelet reactivity(HTPR)to aspirin or clopidogrel.The patients were divided into HTPR group and non-HTPR group.Multivariate logistic regression analysis was used to determine the risk factors for HTPR.Results: A total of 1071 patients were included,of which 293(27.2%)patients were female,with an average age of 57.1 ± 11.1 years.There were 132(12.3%)cases of aspirin HTPR and 204(19.0%)cases of clopidogrel HTPR.Multivariate logistic regression analysis showed that history of stroke(OR=1.875,95% CI 1.216-2.892)and low-density lipoprotein(OR=1.393,95% CI 1.146-1.694)were the risk factors of aspirin HTPR.Female(OR=2.447,95% CI 1.739-3.444),age(OR=1.016,95% CI 1.000-1.032)and diabetes(OR=1.431,95% CI 1.020-2.007)were the risk factors for clopidogrel HTPR.Conclusions: The incidence of HTPR of clopidogrel is higher than that of aspirin,and their risk factors are different.History of stroke and low-density lipoprotein levels were associated with aspirin HTPR.Gender,age and history of diabetes are risk factors for clopidogrel HTPR.Therefore,more individualized treatment may be required for special populations such as women,older adults,or patients with a history of stroke,diabetes mellitus,and high level of low density lipoproteinemia.Part 2: Predictive value of platelet reactivity for early bleeding risk after treatment in acute ischemic stroke patientsObjective: Reducing platelet aggregation and reducing thrombosis can effectively prevent stroke recurrence,but the risk of bleeding increased at the same time.When antiplatelet drugs inhibit the platelet function excessively,the patient is at increased risk of bleeding events.This study aimed to investigate the relationship between platelet reactivity and early bleeding events in acute ischemic stroke patients followed aspirin and clopidogrel.Methods: Patients with acute cerebral infarction were consecutively included,and their clinical data,laboratory examinations and imaging data were collected.Platelet reactivity to aspirin and clopidogrel was measured based on thromboelastometry,expressed as arachidonic acid induced inhibition of platelet aggregation(AA%)or adenosine diphosphate-induced inhibition of platelet aggregation(ADP%),respectively.The bleeding status of the patients within 1 month after dual antiplatelet therapy was followed up and all patients were divided into bleeding event group and non-bleeding event group.Binary logistic regression analysis was used to establish a predictive model for early bleeding risk,and the predictive value was assessed by receiver operating characteristic curve(ROC).Results: A total of 859 patients were included,of which 61(7.1%)patients had bleeding events.Compared with the non-bleeding event group,patients in the bleeding event group had higher levels of NIHSS scores,fasting blood glucose,fibrinogen,D-dimer and ADP% levels(P<0.05).And it was found that D-dimer(OR=1.731,95% CI 1.188-2.573),NIHSS score(OR=1.181,95% CI 1.064-1.311)and ADP%(OR=1.020,95% CI 1.001-1.039)levels were still associated with bleeding events.ROC analysis showed that ADP%(AUC=0.665,95% CI 0.573-0.767,P<0.01)and the Logistic model was(AUC=0.720,95% CI 0.625-0.858,P<0.01)could predict the bleeding events.Conclusions: ADP% is associated with bleeding events after dual antiplatelet therapy in acute ischemic stroke patients.Logistic regression model based on ADP%,D-dimer level and NIHSS score helps to predict early bleeding events after dual antiplatelet therapy in acute ischemic stroke patients.These results may help guide treatment strategies for patients with acute ischemic stroke.Part 3:Correlation between platelet reactivity and characteristics of cerebral atherosclerotic lesions in patients with acute ischemic strokeObjective: Platelets play a crucial role in the process of acute thrombosis.However,it cannot be ignored that platelets,as a part of inflammatory mediators,also play an important role in the formation and progression of atherosclerotic plaques.Studies have reported that baseline platelet function is closely related to platelet reactivity after aspirin or clopidogrel treatment,and when baseline platelet function is higher,high on-treatment platelet reactivity(HTPR)is more likely to occur after antiplatelet drug therapy.Based on this association,clopidogrel HTPR was found to be positively associated with coronary atherosclerosis burden in patients with coronary heart disease.However,the relationship between platelet reactivity and the characteristics of cerebral atherosclerotic lesions remains unclear.Methods: Patients with acute atherosclerotic cerebral infarction followed aspirin and clopidogrel were consecutively enrolled.The platelet reactivity to aspirin and clopidogrel was detected by thromboelastometry,expressed as Arachidonic Acid induced inhibition of platelet aggregation(AA%)or Adenosine Diphosphate induced inhibition of platelet aggregation(ADP%).Aspirin HTPR is defined as AA%<50% and clopidogrel HTPR is defined as ADP%<30%.All patients completed cerebrovascular examination and highresolution magnetic resonance imaging of the vessel wall.Single-vessel disease was defined as a stenosis rate of more than 50% in only one major cerebral artery segment,and Multivessel disease was defined as a stenosis of more than 50% in ≥2 major cerebral artery segment.The patients were grouped by multi-vessel disease and single-vessel disease.The relationship between platelet reactivity and multi-vessel disease was investigated by multivariate logistic regression analysis.Considering that the degree of plaque enhancement is associated with symptomatic arterial stenosis,some of the diseased vessels in the multivessel disease group were asymptomatic arterystenosis.Therefore,the relationship between platelet reactivity and the degree of responsible plaque enhancement was only further explored in patients with single-vessel disease.According to the enhancement degree of responsible plaques,the patients were divided into obvious enhancement group and nonobvious enhancement group.A multivariate logistic regression model was used to adjust the confounding factors to determine the relationship between platelet reactivity and the enhancement degree of responsible plaques.Results: A total of 190 patients were analysised,of which 66(34.7%)patients with multivessel disease.Compared with single-vessel disease group,patients had lower levels of ADP% and higher ratios of clopidogrel HTPR in multi-vessel disease group.After confounding factors such as gender,age,and vascular risk factors were adjusted by multivariate logistic regression models,ADP%(OR=0.986,95% CI 0.972-1.000,P=0.049)and clopidogrel HTPR(OR=2.066,95% CI 1.067-3.998,P=0.043)was independently associated with multi-vessel disease.In a further analysis of 124 patients with single-vessel disease,76(61.3%)patients have obvious plaque enhancement.There was no significant difference in the ADP% level and the incidence of clopidogrel HTPR between the obvious enhancement group and non-obvious enhancement group.Conclusions: ADP% and clopidogrel HTPR are associated with the burden of cerebral atherosclerosis in patients with acute large-artery atherosclerotic cerebral infarction.However,no statistical association was found between clopidogrel HTPR and focal plaque enhancement in cerebral arterial lesions.Further studies on the association between platelet reactivity and plaque characteristics are needed in the future.Part 4: Correlation of plasma exosomal miRNAs with cerebral atherosclerotic disease and platelet reactivityObjective: As a new carrier for the exchange and communication of genetic material between cells,exosomal miRNAs are involved in platelet function regulation and atherogenesis.According to previous findings,high on-treatment platelet reactivity(HTPR)is closely related to cerebral atherosclerosis burden.In order to further explore the potential mechanism of the relationship,this study used high-throughput sequencing technology to detect and screen the differentially expressed plasma exosomal miRNAs in patients with symptomatic intracranial arterial stenosis(sICAS),and explored the relationship between these exosomal miRNAs and clopidogrel HTPR.Methods: This study selected 10 patients with sICAS and 10 healthy volunteers during the same period.High-throughput sequencing technology was used to identify the differential genes between the two groups.In addition,61 sICAS patients and 27 healthy volunteers were prospectively selected,and q RT-PCR was used to verify the differentially expressed miRNA.The 61 sICAS patients were further divided into clopidogrel HTPR group and clopidogrel non-HTPR group.Logistic regression analysis was used to explore the correlation between miRNA and clopidogrel HTPR in sICAS patients.Results: Using high-throughput sequencing technology,81 significantly differentially expressed plasma exosomal miRNAs related to sICAS were screened,of which 71 were upregulated and 10 were down-regulated.According to the sequencing results,combined with literature review and expression levels,six miRNAs were further verified(including hsamiR-10b-5p,hsa-miR-320 d,hsa-miR-21-5p,hsa-miR-17-5p,hsa-miR-193a-5p and hsamiR-224-5p).The 6 differentially expressed exosomal miRNAs were verified by q RT-PCR method,and it was found that the change trend of their expression levels was consistent with the sequencing results.After adjusting the confounding factors,it was found that hsamiR-224-5p and hsa-miR-193a-5p were associated with sICAS.The relationship between these 6 differentially expressed miRNAs and clopidogrel HTPR in sICAS patients was further explored,and it was found that the increased expression level of hsa-miR-21-5p was associated with clopidogrel HTPR(OR=1.138,95% CI 1.113-1.769,P=0.009).Conclusions: Has-miR-21-5p is a relatively widely studied miRNA,not only asscotated with sICAS,but also the efficacy of clopidogrel,and may also be involved in the regulation of platelet function.However,larger studies are needed to assess the robustness of this result.