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- Page navigation anchor for RE: Differential effect of ticagrelor versus clopidogrel by homocysteine levels on risk of recurrent stroke: a post hoc analysis of the CHANCE-2 trialRE: Differential effect of ticagrelor versus clopidogrel by homocysteine levels on risk of recurrent stroke: a post hoc analysis of the CHANCE-2 trial
Dear Editor,
I am writing to address some significant concerns arising from the recent publication titled "Differential effect of ticagrelor versus clopidogrel by homocysteine levels on risk of recurrent stroke: a post hoc analysis of the CHANCE-2 trial." This study offers intriguing insights into the potential interplay between homocysteine levels and the efficacy of dual antiplatelet therapy in preventing recurrent stroke among patients with minor ischemic stroke or transient ischemic attack (TIA). However, upon closer examination, several methodological and clinical considerations merit thorough scrutiny.
First and foremost, while the study endeavors to unravel the intricate relationship between homocysteine levels and treatment response, its post hoc design raises inherent limitations. The exclusion of a substantial subset of patients due to missing homocysteine data introduces the possibility of selection bias, potentially compromising the internal validity of the findings. Moreover, the study's reliance on patients carrying CYP2C19 loss-of-function alleles limits the generalizability of the results to a specific genetic subgroup, overlooking the broader heterogeneity of stroke etiology and treatment response.
Furthermore, the authors' interpretation of the differential efficacy of ticagrelor versus clopidogrel based on homocysteine levels warrants cautious consideration. While the study suggests a synergistic relationship betw...
Show MoreCompeting Interests: None declared.References
- 1. Wand A, Tian X, Xie X, et al. Differential effect of ticagrelor versus clopidogrel by homocysteine levels on risk of recurrent stroke: a post hoc analysis of the CHANCE-2 trial. CMAJ 2024;196(5): E149-E156.
- 2. Coull AJ, Lovett JK, Rothwell PM. Population based study of early risk of stroke after transient ischaemic attack or minor stroke: implications for public education and organisation of services. BMJ 2004;328:326.
- 3. Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after transient ischemic attack or minor stroke. N Engl J Med 2016;374:1533-42.
- 4. Lentz SR. Mechanisms of homocysteine-induced atherothrombosis. J Thromb Haemost 2005;3:1646-54.