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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:
Is early dual antiplatelet therapy superior to mono antiplatelet therapy in acute non-cardioembolic ischemic stroke or transient ischemic attack (TIA)?
Methods:
This systemic review and meta-analysis examined 14 randomized controlled trials with 9,012 patients comparing dual versus mono antiplatelet therapy in patients with acute non-cardioembolic ischemic stroke or TIA, and compared the safety and efficacy of these approaches in patients treated within 3 days of onset.
Results:
In the meta-analysis, dual (vs. mono) antiplatelet treatment was associated with reduced stroke recurrence (risk ratio [RR], 0.69; 95% confidence interval [CI], 0.60-0.80; p < 0.001) and reduced rates of the composite endpoint of stroke, TIA, acute coronary syndrome, and all-cause mortality (RR, 0.71; 95% CI, 0.63-0.81; p < 0.001). In regards to major bleeding, there was no significant difference between dual and mono antiplatelet therapy (RR, 1.35; 95% CI, 0.70-2.59; p = 0.37). When analyses were limited to studies that excluded the CHANCE trial, the RR (0.66; 95% CI, 0.48-0.91) for recurrent stroke was similar to that observed in the CHANCE trial population alone (RR, 0.70; 95% CI, 0.59-0.83); similarly, rates of composite adverse events were also comparable between these subgroups.
Conclusions:
The early use of dual antiplatelet therapy is superior to mono antiplatelet therapy in preventing recurrent strokes and composite vascular events in patients with non-cardioembolic ischemic stroke or TIA, without a significant difference in risk of major bleeding.
Perspective:
This study supports the use of early dual antiplatelet therapy following non-cardioembolic ischemic stroke or TIA, although many questions remain to be answered. As approximately one-half of the meta-analysis population came from the CHANCE trial, the authors also examined cohorts with and without this study, and observed comparable results, which further support the overall findings. Major limitations of these results include the use of different dual antiplatelet therapies between studies, alternate duration of dual antiplatelet treatment, and differences in treatment onset, stroke severity, and study populations. Most importantly, we still need to determine which dual antiplatelet regimen results in the best outcomes, and to identify the optimal duration of these therapies.
Keywords: Acute Coronary Syndrome, Stroke, Ischemic Attack, Transient
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