Apolipoprotein E phenotype and the efficacy of intravenous tissue plasminogen activator in acute ischemic stroke

We used stored plasma samples from 409 patients in the National Institute o f Neurological Diseases and Stroke (NINDS) tissue plasminogen activator (t- PA) Stroke Trial to examine the relationship between an apolipoprotein (Apo ) E2 or an Apo E4 phenotype and a favorable outcome 3 months after stroke, the risk of intracerebral hemorrhage, and the response to intravenous t-PA therapy. For the 27 patients with an Apo E2 phenotype who were treated with t-PA, the odds ratio (OR) of a favorable outcome at 3 months was 6.4 [95% confidence interval (CI) 2.7-15.3%] compared to the 161 patients without an Apo E2 phenotype who were treated with placebo. The 190 patients treated w ith t-PA who did not have an Apo E2 phenotype also had a greater, though le ss pronounced, likelihood of a favorable outcome (OR 2.0, 95% CI 1.2-3.2%) than patients without an Apo E2 phenotype treated with placebo. For the 31 patients with an Apo E2 phenotype treated with placebo, the OR of a favorab le 3 month outcome was 0.8 (95% CI 0.4-1.7%) compared to the 161 patients w ithout an Apo E2 phenotype treated with placebo. This interaction between t reatment and Apo E2 status persisted after adjustment for baseline variable s previously associated with 3 month outcome, for differences in the baseli ne variables in the two treatment groups and in the Apo E2-positive and -ne gative groups, and for a previously reported time-to-treatment x treatment interaction (p = 0.03). Apo E4 phenotype, present in 111 (27%) of the 409 p atients, was not related to a favorable 3 month outcome, response to t-PA, 3 month mortality, or risk of intracerebral hemorrhage. We conclude that th e efficacy of intravenous t-PA in patients with acute ischemic stroke may b e enhanced in patients who have an Apo E2 phenotype, whereas the Apo E2 phe notype alone is not associated with a detectable benefit on stroke outcome at 3 months in patients not given t-PA. In contrast to prior studies of hea d injury and stroke, we could not detect a relationship between Apo E4 phen otype and clinical outcome.