Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): effects on outcomes at day 365 in a randomised, sham-controlled, blinded, phase III, superiority ambulance-based trial

Woodhouse, Lisa J; Appleton, Jason P; Ankolekar, Sandeep; England, Timothy J; Mair, Grant; Muir, Keith; Price, Christopher I; Pocock, Stuart; Randall, Marc; Robinson, Thompson G; Roffe, Christine; Sandset, Else C; Saver, Jeffrey L; Siriwardena, Aloysius Niroshan; Sprigg, Nikola; Wardlaw, Joanna M; Bath, Philip M

Abstract

Background The Rapid Intervention with Glyceryl Trinitrate in Hypertensive Stroke Trial-2 (RIGHT-2) reported no overall treatment difference between glyceryl trinitrate (GTN) and sham at day 90. Here we assess participants' outcomes 1 year after randomisation. Methods RIGHT-2 was an ambulance-based prospective randomised controlled trial where patients with presumed stroke and systolic blood pressure (BP) of >120 mm Hg received either GTN (5 mg/day) or sham patch. Centralised blinded telephone follow-up was performed at days 90 (primary endpoint) and 365 (secondary endpoint). The lead outcome was dependency assessed with the modified Rankin Scale (mRS). Results 1149 patients were recruited to RIGHT-2 between October 2015 and May 2018, and 1097 (95.5%) had outcome data recorded at day 365. At baseline, the patients were; female (48%), had a mean age of 73 (15) years, BP of 162 (25)/92 (18) mm Hg, onset to randomisation of 70 (45-115) min, diagnosis of ischaemic stroke (52%), intracerebral haemorrhage (ICH) (13%), transient ischaemic attack (TIA) (9%) and mimics (26%). There was no effect of GTN on mRS score at day 365 in participants with confirmed stroke/TIA (adjusted common odds ratio (acOR) 1.10, 95% CI 0.86 to 1.42) or in all patients. In patients randomised to GTN, mRS at day 365 tended to be worse in those with ICH (acOR 1.65, 95% CI 0.84 to 3.25) and better in those with a mimic diagnosis (acOR 0.53, 95% CI 0.33 to 0.84). Conclusion At 1 year post randomisation, dependency did not differ between GTN and sham treatment in either the target population or overall. In prespecified subgroup analyses, GTN was associated with reduced dependency in participants with a final diagnosis of mimic and a non-significant worse outcome in participants with ICH. Trial registration number ISRCTN26986053.

Citation

Woodhouse, L. J., Appleton, J. P., Ankolekar, S., England, T. J., Mair, G., Muir, K., …Bath, P. M. (2023). Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): effects on outcomes at day 365 in a randomised, sham-controlled, blinded, phase III, superiority ambulance-based trial. BMJ Neurology Open, 5(1), Article e000424. https://doi.org/10.1136/bmjno-2023-000424

• Journal Article Type: Article
• Acceptance Date: May 11, 2023
• Online Publication Date: Jun 27, 2023
• Publication Date: Jun 27, 2023
• Deposit Date: May 18, 2023
• Publicly Available Date: Jul 4, 2023
• Journal: BMJ Neurology Open
• Electronic ISSN: 2632-6140
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• Volume: 5
• Issue: 1
• Article Number: e000424
• DOI: https://doi.org/10.1136/bmjno-2023-000424
• Keywords: Cerebral blood flow, stroke, randomised trials, cerebrovascular disease
• Public URL: https://nottingham-repository.worktribe.com/output/20836672
• Publisher URL: https://neurologyopen.bmj.com/content/5/1/e000424