Antiplatelet in Stroke: Safety and Effectiveness in Seniors (ASSESS)

目前的美国和欧洲指南建议抗血小板治疗，如阿司匹林，氯吡格雷，或双重 抗血小板治疗降低非心源性栓塞性缺血性脑卒中患者缺血性事件复发的风险 中风然而，选择抗血小板药物可能是一个困难的决定，使老年患者。不仅 老年人复发中风的风险增加，他们还面临出血并发症的风险。而 众所周知，药物选择应个体化，但如何定制抗血小板治疗仍是未知数， 根据患者独特的特征、偏好、需求和价值观。长期目标是使用COM- 对比有效性研究，以改善心血管疾病的一级和二级预防， 中风利用美国心脏协会（AHA）卒中指南（GWTG）登记研究， 医疗保险索赔，在这个应用程序的总体目标是制定以病人为中心的循证策略 改善老年非心源性栓塞性缺血性卒中患者的抗血小板治疗选择。 中心假设是个体在许多特征上不同，如年龄、性别、是否存在共病- 可能影响治疗相关潜在获益和危害的药物或合并用药- 我是说。一旦知道了对治疗反应的变异性，就可以选择抗血小板药物 基于患者的风险特征、偏好和已知的药物疗效/安全性， 更有效。在强有力的初步数据的指导下，这一假设将通过追求三个具体的 目的：1）确定不同抗血小板治疗方案对非血小板聚集患者的长期临床疗效， 血栓栓塞性缺血性卒中; 2）确定不同抗血小板治疗方案的长期安全性; 3）平衡 每种抗血小板治疗方案的益处和危害，同时将患者偏好纳入决策。 该研究在四个方面具有创新性：1）以患者为中心的方法用于解决真实的- 脑卒中幸存者和临床医生面临的生活决策困境; 2）它将重点从临床研究中的选定样本转移到 对全国代表性卒中人群的试验，包括传统上代表性不足的亚组， 社区实践; 3）新的倾向得分逆概率加权方法，使用广义提升模型， els（一种机器学习技术）将被用来模拟试验型多治疗设计，揭示治疗， 4）超越传统的遗传学机制， 科学出版物，本研究产生的证据将传播给中风幸存者，临床医生， 通过AHA GWTG领导的国家质量倡议和患者主导的努力， 将开创性的发现迅速转化为临床实践。这项研究意义重大，因为它 预计将有助于指导老年缺血性卒中幸存者的个性化抗血小板治疗， 他们的需求，并导致更好的结果最有意义的病人。最终，这种知识具有潜力- 该研究旨在为中风的循证治疗决策提供信息，目前有超过720万美国人受到中风的折磨。

The current U.S. and European guidelines recommend antiplatelet therapy such as aspirin, clopidogrel, or dual antiplatelet therapy to reduce the risk of recurrent ischemic events in patients with noncardioembolic ischemic stroke. However, selection of antiplatelet agents can be a difficult decision to make for older patients. Not only older individuals are at increased risk for recurrent strokes, they also face risk for bleeding complications. While it is known that drug selection should be individualized, it remains unknown how to tailor antiplatelet therapy according to patient unique characteristics, preferences, needs, and values. The long-term goal is to use com- parative effectiveness research to improve primary and secondary prevention in cardiovascular disease and stroke. Leveraging the American Heart Association (AHA) Get With The Guidelines Stroke (GWTG) registry and Medicare claims, the overall objective in this application is to develop patient-centered evidence-based strategies to improve antiplatelet treatment selection for older individuals presenting with noncardioembolic ischemic stroke. The central hypothesis is that individuals differ in many characteristics, such as age, sex, presence of comorbid- ities, or concurrent medications, which can influence the potential benefits and harms associated with the treat- ment. Once the variability in response to treatment is known, selection of an antiplatelet agent can be made based on patient risk profiles, preferences, and known efficacy/safety of the agents, making treatment both safer and more effective. Guided by strong preliminary data, this hypothesis will be tested by pursuing three specific aims: 1) determine the long-term clinical effectiveness of different antiplatelet regimens in patients with noncar- dioembolic ischemic stroke; 2) determine the long-term safety of different antiplatelet regimens; and 3) balance benefits and harms of each antiplatelet regimen while incorporating patient preferences into decision-making. The proposed research is innovative in four key ways: 1) a patient-centered approach is used to address a real- life decisional dilemma facing stroke survivors and clinicians; 2) it shifts focus from selected samples in clinical trials to nationwide representative stroke population, including traditionally underrepresented subgroups in com- munity practice; 3) novel propensity score inverse probability weighting method using generalized boosted mod- els (a machine learning technique) will be employed to mimic a trial-type multi-treatment design, uncover treat- ment heterogeneity, and minimize selection bias in observational data; 4) beyond traditional mechanisms of scientific publications, the evidence generated from this study will be disseminated to stroke survivors, clinicians, and relevant stakeholders through the AHA GWTG-led national quality initiatives and patient-led efforts to insure a rapid translation of seminal findings into clinical practice. The proposed research is significant, because it is expected to help guide personalized antiplatelet therapy in older ischemic stroke survivors that could best meet their needs and lead to better outcomes most meaningful to patients. Ultimately, such knowledge has the poten- tial to inform evidence-based treatment decisions in stroke that now afflicts more than 7.2 million Americans.