Dual Antiplatelet Therapy vs. Aspirin in Stroke or TIA

May 05, 2021
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Authors:
Bhatia K, Jain V, Aggarwal D, et al.
Citation:
Dual Antiplatelet Therapy Versus Aspirin in Patients With Stroke or Transient Ischemic Attack: Meta-Analysis of Randomized Controlled Trials. Stroke 2021;Apr 27:[Epub ahead of print].
Summary By:
Mollie McDermott, MD, MS

Quick Takes

  • Whereas long-term dual antiplatelet therapy (DAPT) after stroke is not recommended, recent randomized controlled trials have suggested a role for short-term DAPT with aspirin and clopidogrel after stroke.
  • In this meta-analysis of four relevant trials, short-term DAPT was associated with a reduced risk of recurrent stroke (hemorrhagic or ischemic) compared to aspirin monotherapy.
  • Whether short-term treatment with aspirin plus clopidogrel or short-term treatment with aspirin plus ticagrelor is superior remains unclear.

Study Questions:

Is antiplatelet monotherapy or dual antiplatelet therapy (DAPT) better in the short-term after minor acute ischemic stroke or transient ischemic attack (TIA)?

Methods:

This is a meta-analysis of trials that randomized adult patients with acute stroke or TIA to receive either antiplatelet monotherapy or DAPT with aspirin and a P2Y12 inhibitor started within 24 hours of stroke symptom onset. Patients were not included if they received intravenous tissue plasminogen activator or if mechanical thrombectomy was planned. The primary outcome of interest was hemorrhagic or ischemic stroke.

Results:

Four randomized controlled trials with a total of 21,459 patients were included in the meta-analysis. Three trials (FASTER, CHANCE, and POINT) compared aspirin to DAPT with clopidogrel and aspirin. One trial (THALES) compared aspirin to DAPT with ticagrelor and aspirin. DAPT duration ranged from 21-90 days. In comparison to aspirin monotherapy, patients treated with DAPT had a lower risk of recurrent stroke (relative risk [RR], 0.76; 95% confidence interval [CI], 0.68–0.83), but a higher risk of major bleeding (RR, 2.22; 95% CI, 1.14–4.34). No difference in all-cause mortality was observed between the two groups.

Conclusions:

In this meta-analysis of four relevant trials, short-term DAPT was associated with a reduced risk of recurrent stroke (ischemic or hemorrhagic) compared to aspirin monotherapy. While DAPT was associated with a greater risk of major bleeding, no difference in death was observed between the two groups.

Perspective:

Based on the positive results of the CHANCE trial in 2013 and the POINT trial in 2018, the stroke community has largely adopted the guideline-concordant use of DAPT with aspirin and clopidogrel for 21 days after minor stroke or high-risk TIA. Whether short-term treatment with aspirin and clopidogrel or short-term treatment with aspirin and ticagrelor is superior remains unclear. The CHANCE 2 trial is currently enrolling and will compare the two approaches.

Clinical Topics: Prevention, Vascular Medicine

Keywords: Aspirin, Brain Ischemia, Cerebral Infarction, Hemorrhage, Ischemic Attack, Transient, Ischemia, Platelet Aggregation Inhibitors, Risk, Secondary Prevention, Stroke, Vascular Diseases


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