Antiplatelet therapy for primary prevention of stroke in patients with carotid web: a prospective cohort study

Background Carotid webs have emerged as an etiology for ischemic stroke in younger patients, with a high recurrence rate. However, the optimal prevention strategy for asymptomatic carotid webs remains uncertain. Methods This prospective cohort study was conducted at the Affiliated Hospital of Qingdao University between June 2017 and June 2022, including patients diagnosed with asymptomatic carotid webs via CT angiography (CTA), to evaluate the efficacy of antiplatelet therapy as primary prevention of stroke. The primary outcome was the incidence of ischemic stroke. Patients receiving oral anticoagulants or with other etiologies for stroke were excluded. Cox regression with Firth’s penalized maximum likelihood method was used to evaluate the association between antiplatelet therapy and stroke. Propensity scores were applied in sensitive analysis. Results A total of 105 patients (median age, 61 years; range, 19–80 years), including 53 (50.5%) male patients, were included. Altogether 31 patients received single antiplatelet therapy. During a median follow-up of 31 months (range from 9 to 89 months), ischemic stroke occurred in 3 of 31 patients (incidence rate, 3.51 per 100 person-years, 95% CI = 0.72–10.25) in the antiplatelet group and 10 of 74 patients (5.16 per 100 person-years, 95% CI = 2.18–9.50) in the non-antiplatelet group. The estimated association favored antiplatelet therapy but was imprecise (HR = 0.755, 95% CI = 0.215–2.653, p = 0.642). Similar results were observed after adjustment for atherosclerotic cardiovascular disease (ASCVD) risk and concurrent stenosis, as well as in propensity score-adjusted analyses. Subgroup analysis of patients without high ASCVD risk demonstrated no significant association between antiplatelet therapy and stroke (HR = 0.671, 95% CI = 0.108–4.191, p = 0.638). Conclusion In this prospective cohort, stroke incidence was numerically lower with single antiplatelet therapy, but estimates were imprecise and compatible with both benefit and harm.