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Aspirin and Clopidogrel vs. Aspirin in Acute Minor Stroke or TIA
Study Questions:
Do patients with acute noncardioembolic minor stroke do better on short-term aspirin monotherapy or short-term dual therapy with aspirin and clopidogrel?
Methods:
This is a prospective registry-based observational study of consecutive acute stroke/transient ischemic attack (TIA) patients admitted to 15 academic hospitals in South Korea. Eligible patients were ≥40 years of age, had a minor ischemic stroke (National Institutes of Health Stroke Scale [NIHSS] score <4) or TIA with positive imaging, and were within 24 hours of symptom onset. Patients with cardioembolic stroke were not included given the need for anticoagulation. The primary outcome was the composite of ischemic stroke, hemorrhagic stroke, myocardial infarction, and vascular death at 3 months post-stroke. Propensity score matching was used to control for baseline differences between the aspirin-only group and the aspirin-clopidogrel group.
Results:
A total of 5,590 patients met inclusion criteria. Median NIHSS score was 1. Patients in the clopidogrel-aspirin group were more likely to have had a previous stroke/TIA and to already be on an antiplatelet, antihypertensive, and/or statin. Prior to propensity score weighting, the primary outcome occurred less frequently in the aspirin-clopidogrel group compared to the aspirin-only group (9.9% vs. 12.2%, p = 0.009). After propensity score weighting, aspirin-clopidogrel therapy remained superior, with the primary outcome occurring 24% less frequently in the aspirin-clopidogrel group than in the aspirin-only group (relative risk, 0.76; 95% confidence interval, 0.63-0.92). Patients who were on an antiplatelet at the time of the index TIA/stroke seemed to benefit more from aspirin-clopidogrel therapy (hazard ratio, 0.50 vs. 0.86; p for interaction = 0.01).
Conclusions:
As in the recent randomized controlled CHANCE and POINT trials, patients with acute stroke/TIA in this observational study did better on short-term aspirin-clopidogrel therapy than short-term aspirin monotherapy.
Perspective:
Although two recent randomized controlled trials (RCTs) have addressed the efficacy of short-term aspirin-clopidogrel versus aspirin after TIA/stroke, the authors performed the current analysis to evaluate the effectiveness of clopidogrel-aspirin versus aspirin in patients “encountered in routine clinical practice.” However, this study was limited to academic hospitals in South Korea and is therefore of arguable generalizability. Given the existence of two high-quality RCTs that have shown a benefit of short-term aspirin-clopidogrel after TIA/stroke, the current study does little to advance the literature.
Clinical Topics: Cardiovascular Care Team, Prevention
Keywords: Antihypertensive Agents, Aspirin, Brain Ischemia, Ischemic Attack, Transient, Myocardial Infarction, Platelet Aggregation Inhibitors, Primary Prevention, Risk, Stroke, Thrombolytic Therapy, Vascular Diseases
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