In patients with minor ischemic stroke or transient ischemic attack, identifying subgroups that derive greater benefit from specific dual antiplatelet strategies remains a clinical challenge. In the Journal of the American Heart Association, investigators report a post hoc analysis of the CHANCE-2 (Ticagrelor or Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events II) trial examining whether vascular cellular adhesion molecule-1 (VCAM-1) levels and stroke cause classification modify treatment effects.

The analysis included 5,651 patients with a median age of 64.8 years, including 1,908 women. Patients were categorized by ischemic stroke cause using the Causative Classification of Stroke system and stratified by baseline VCAM-1 level. The primary outcome was any stroke within 90 days. Cumulative incidence was compared using Kaplan-Meier analysis and log-rank testing, with Cox proportional hazards models used to estimate hazard ratios and 95% confidence intervals.

Among patients with nonelevated VCAM-1 levels (<1715.9 ng/mL) and small artery occlusion subtype (n=1,252), ticagrelor-aspirin was associated with a lower risk of recurrent stroke compared with clopidogrel-aspirin (2.9% vs 7.5%; hazard ratio, 0.37; 95% CI, 0.22–0.64; P<0.001). Mild bleeding occurred more frequently with ticagrelor–aspirin (6.7% vs 1.4%; hazard ratio, 4.85; 95% CI, 2.36–9.96), while no significant differences were observed in moderate or severe bleeding.

The analysis showed that VCAM-1 level and ischemic stroke cause classification were associated with differential benefit from ticagrelor-aspirin within 90 days.