Tirofiban added to aspirin did not prevent deterioration in branch atheromatous stroke

Design

Multicentre, double-blind, randomised, placebo-controlled trial

Population

970 adults with MRI-confirmed branch atheromatous disease stroke within 48 hours

Primary outcome

Early neurological deterioration within 7 days or new stroke within 90 days

Effect

17.1% vs 19.6%; HR 0.88 (95% CI 0.65–1.19)

Branch atheromatous disease — occlusion at the mouth of a deep penetrating artery by parent-vessel plaque — causes small subcortical infarcts that often worsen over the first days. STRATEGY randomised 970 patients at 38 Chinese hospitals, within 48 hours of an MRI-confirmed branch atheromatous stroke, to intravenous tirofiban for 24 hours or placebo, on top of aspirin for 90 days. It was double-blind.

Early neurological deterioration within 7 days or new stroke within 90 days occurred in 17.1% with tirofiban and 19.6% with placebo (HR 0.88, 95% CI 0.65–1.19; P = 0.39). Moderate or severe bleeding was rare in both groups (1 patient against none).

The trial does not support routine tirofiban for this stroke subtype. The comparator was aspirin alone, not the dual antiplatelet therapy many clinicians now use for minor stroke, so the result says nothing about tirofiban against clopidogrel plus aspirin. The trial population was Chinese, where intracranial atherosclerosis is common; that also makes it relevant to Indian practice.

• Do not add intravenous tirofiban routinely for branch atheromatous disease stroke on this evidence.
• Watch closely for early deterioration in the first week after a small deep infarct.
• Use MRI where available to identify branch atheromatous disease patterns.
• Apply dual antiplatelet therapy for minor stroke per current guidance; this trial did not test it.
• Bleeding was rare with tirofiban, so safety was not the reason for the neutral result.

Why it matters

Intensive antiplatelet therapy for early deterioration has been spreading on observational grounds, and a randomised test did not support it.

Don't overread it

The trial compared tirofiban with aspirin alone, so it does not settle tirofiban against dual antiplatelet therapy.

The statistics, in plain English

A hazard ratio of 0.88 with an interval from 0.65 to 1.19 means the data fit anything from a 35% reduction to a 19% increase. The trial could not rule out a modest benefit, but it did not show one.

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