ESOC 2025 | Debate at ESOC 2025: do add-on antithrombotics improve outcomes with reperfusion therapy?

So just in this conference we have seen the results of the ASSET-IT trial. This trial tested tirofiban, which is a potent, fast-acting antiplatelet drug. It’s an inhibitor of the glycoprotein 2B3A receptor. And this study has shown that in patients that receive IV thrombolysis, if they receive tirofiban, excluding patients with atrial fibrillation and those that were candidates for endovascular therapy, the addition of IV tirofiban in the acute phase of stroke within the first minutes after thrombolysis was helpful to improve functional outcomes of the patients and it was safe. So this is an important point. I think it’s a trial that excluded patients with cardioembolic disease who have a low probability of benefit of additional antithrombotic therapy. On the other hand, it really focuses on the patients that have atherosclerotic intracranial or extracranial disease, which I think is the most important target for this kind of treatment strategy. So it was a successful trial. And then we have also other trials right now that have shown a clear signal for additional antithrombotic therapy in the setting of endovascular therapy, in the setting of tandem occlusions, and also for patients that have intracranial atherosclerosis. So I think that we are now moving into the field that we may have to select patients and, according to the etiology, select the best antithrombotic therapy for them in the acute setting of stroke. Of course, there’s a lot of concern about adding additional antithrombotic therapy in the setting of acute hyperperfusion, given the fact that we are all concerned with the risk of intracranial hemorrhage, symptomatic intracranial hemorrhage. And I think that she correctly pointed out that we still need to be careful about adding additional layers of treatment on thrombotic therapies in general for patients with acute ischemic stroke in the setting of thrombolysis. So I think that the best approach would be to combine these arguments and to be more selective to address this. And I think that the important point is to focus on the patient with a high risk of clinical deterioration and also with reocclusion. And those for sure are the ones that have intracranio-arterial disease. I think that’s the main target for additional antithrombotic therapy in the sector of ischemic stroke.

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