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Early Dual Versus Mono Antiplatelet Therapy for Acute Non-Cardioembolic Ischemic Stroke or Transient Ischemic Attack: An Updated Systematic Review and Meta-Analysis
Study Questions:
What is the efficacy and safety of dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke (IS) or transient ischemic attack (TIA)?
Methods:
The investigators assessed randomized controlled trials investigating dual versus mono antiplatelet therapy published up to November 2012, and the CHANCE trial (Clopidogrel in High-Risk Patients With Acute Non-disabling Cerebrovascular Events), for efficacy and safety outcomes in adult patients with acute non-cardioembolic IS or TIA, with treatment initiated within 3 days of ictus. In total, 14 studies of 9,012 patients were included in the systematic review and meta-analysis. For all outcomes, relative risk (RR) and 95% confidence intervals (CIs) were calculated using the DerSimonian and Laird random-effects model.
Results:
Dual antiplatelet therapy significantly reduced risk of stroke recurrence (RR, 0.69; 95% CI, 0.60-0.80; p < 0.001) and the composite outcome of stroke, TIA, acute coronary syndrome (ACS), and all deaths (RR, 0.71; 95% CI, 0.63-0.81; p < 0.001) when compared with monotherapy, and nonsignificantly increased risk of major bleeding (RR, 1.35; 95% CI, 0.70-2.59; p = 0.37). Analyses restricted to the CHANCE trial or the seven double-blind randomized controlled trials showed similar results.
Conclusions:
The authors concluded that for patients with acute non-cardioembolic ischemic stroke or TIA, dual therapy was more effective than monotherapy in reducing risks of early recurrent stroke.
Perspective:
This study reported that when compared with monotherapy for acute non-cardioembolic IS or TIA, dual antiplatelet therapy was associated with a reduction in stroke recurrence and composite vascular events, but without a significant increase in the risk of major bleeding. Based on available data, early use of dual antiplatelet therapy after acute non-cardioembolic IS or TIA for a limited time period appears to be efficacious and safe. Results of two ongoing large trials, POINT (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) and TARDIS (Triple Antiplatelets for Reducing Dependency after Ischemic Stroke), will provide additional insight on optimal antiplatelet therapies for acute IS and TIA.
Keywords: Risk, Acute Coronary Syndrome, Stroke, Ischemic Attack, Transient, Platelet Aggregation Inhibitors, Cardiology, Cardiovascular Diseases, Blood Platelets, Hemorrhage
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