| Objective:The purpose of this study is to explore the independent risk factors for recurrence and prognostic outcomes at 30 days,90 days and 180 days by comparing the periodic survival time,survival outcomes and prognosis in patients with different etiologic types of acute mild ischemic stroke for double antibody therapy and provide a valuable reference for accurate dual antiplatelet therapy in the real world.Methods:1.The study is a prospective cohort study of the real world.We enrolled the patients of acute mild ischemic stroke treated with aspirin and clopidogrel at the First Affiliated Hospital of Guangxi Medical University since November 1,2018 and October 1,2020.2.Collecting the baseline and clinical datas of patients.Such as name,sex,age,the start-up time of double antibody,degree of neurological impairment at the first visit(the evaluation standard is National Institutes of Health Stroke),the level of blood pressure at first visit,hypertension,diabetes,heart diseases,hyperlipidemia,the history of stroke,alcohol and tobacco,homocysteine,the results of laboratory and imaging tests.Assessing the etiology classifications and the risk of stroke by the standard for TOAST and Essen Stroke Risk Score.3.Synchronizing and Registering the patient’s information of 14,30,90 and180 days after the onset of MIS,such as the short-term changes in neurological function(the differencein NIHSS scores between the onset of MIS and 14 days),duration of treatment with double antibody,medicinal compliance,primary,secondary end-point,safety and other events,prognostic outcomes(the evaluation standard is Modified Rankin Score).4.We used the software of SPSS 21.0 for statistical analysis and mapping :1)Analyzing the differences in baseline and clinical datas between the total queue and different TOAST classifications;2)Risk scale model was included after excluding multicollinearity.Multiple stepwise regression analysis was used to obtain relevant independent risk factors of MIS.Screening the univariate analysis of recurrence and prognostic outcomes within the total cohort,excluding multiple collinearity for establishing the risk scale model and screening the multivariate analysis with stepwise regression for obtaining independent risk factors.Finally,we can conduct stratified sensitivity analysis according to TOAST classification.The criterion for the difference of statistical significance is P < 0.05.Results:1.In the real world,293 cases(1.08%)were enrolled in the MIS of dual antibody therapy,including 3 cases of lost follow-up(1.08%),50 cases of recurrence(including death)(17.2%),7 cases of intracranial hemorrhage(2.4%),and 16 cases of other bleeding events other than intracranial hemorrhage(5.5%).Among them,135 cases were large-artery Atherosclerosis(LAA)(46.6%),14 cases were Cardio Embolism(CE)(4.8%),94 cases were Small Artery Occlusion(SAO)(32.4%),22 cases were Stroke of other determined cause(ODC)(7.6%),25 cases were Stroke of undetermined cause(UND)(8.6%).The highest proportion of the study’s types is LAA.2.There are significant differences between different TOAST types on the duration of treatment with double antibody(P=0.002),the short-term changes in neurological function(P=0.045),hyperlipidemia(P=0.011),heart disease(P <0.001),the degree of intracranial artery stenosis(P<0.001),carotid artery plaque(P=0.001)and the group of Essen scores(P=0.023): 1)the highest rate of recurrence is CE type,followed by ODC type,and the lowest rate is SAO type;the survival time of CE type is 180-360 days while the other four types are more than360 days;CE type have the highest incidence of other bleeding events(nonintracranial hemorrhage),the second type is LAA,and the other subtypes are relatively low.2)The highest rate of poor prognosis(MRS≥3)at 90 days after onset of MIS is the UND type,followed by CE type and ODC type,the highest rate of poor prognosis at 180 days after onset of MIS is the ODC type,followed by UND type and CE type,the lowest rate of poor prognosis in the subgroups at90 and 180 days is the SAO type.3.Different TOAST classifications had different independent risk factors for recurrence within the 2-year prospective follow-up of MIS treated by double antibodies in the real world.1)LAA: the duration of the double antibodyand age;2)CE: the degree of intracranial artery stenosis;3)SAO: the history of stroke,the degree of intracranial artery stenosis and medicinal compliance;4)ODC: the duration of the double antibodyand the level of blood pressure at first visit;5)the UND type needs further study.4.Different TOAST classifications had different independent risk factors for poor prognosis at 30 days within the 2-year prospective follow-up of MIS treated by double antibodies in the real world.1)LAA: the Start-up time of double antibody,hyperlipidemia,degree of neurological impairment and low-density lipoprotein at the first visit;2)the CE type needs further study;3)SAO: the history of stroke,age and 2h postprandial blood glucose at the first visit;4)ODC: the duration of the double antibody;5)UND: the duration of the double antibody and the degree of intracranial artery stenosis.5.Different TOAST classifications had different independent risk factors for poor prognosis at 90 days within the 2-year prospective follow-up of MIS treated by double antibodies in the real world.1)LAA: hypertension,hyperlipidemia,low-density lipoprotein and creatine kinase isoenzymeat the first visit;2)the CE type needs further study;3)SAO: hypertension and the degree of neurological impairment at the first visit;4)ODC: medicinal compliance;5)UND: the duration of the double antibody and degree of intracranial artery stenosis.6.Different TOAST classifications had different independent risk factors for poor prognosis at 180 days within the 2-year prospective follow-up of MIS treated by double antibodies in the real world.1)LAA:age,the duration of the double antibody and low-density lipoprotein at the first visit;2)CE: the degree of intracranial artery stenosis;3)SAO: the history of stroke;4)ODC: the total cholesterol at the first visit;5)UND:the duration of the double antibody.7.In the real world,we analyzed the prognosticoutcomes of different TOAST classifications for MIS treated by unloaded effective dose of double antibody,and founded that the risk of poor prognosis at 30 days for activating the dual antibody within 24 hours was higher than activating the dual antibody after 24 hours,the risk of recurrence and some periods of poor prognosis with the maintenance of dual antibody less than 21 dayswere higher than the maintenance of dual antibody at least 21 days,but only in LAA type,UND type,and ODC type,the difference is significant.So,in the real world,whether there is an optimal target for the startup time and duration of double antibody in patients with the acute phase of different etiological MIS? All these questions need further study.Conclusion:1.In the real world,we founded that the highest rates and safe of recurrence andsafety end events(the other bleeding events other than intracranial hemorrhage)were the CE type,the highest rate of poor prognosis at90 days was the UND type,the lowest rates of poor prognosis at 90 days and 180 days were the SAO type within the 2-year prospective follow-up of MIS treated by double antibodies.2.In the real world,we founded that the independent risk factors for the 2-year survival outcome and the 30-day,90-day,and 180-day prognostic outcomes of each TOAST classification were different within the 2-year prospective followup of MIS treated by double antibodies.3.Precise dual-antiplatelet preventions and treatments based onetiology in patients with MIS in the real world have clinical significance and in-depth research value. |
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