Dual vs. Monotherapy Antiplatelet Agents in Secondary Stroke Prevention

May 12, 2021
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Authors:
Trifan G, Gorelick PB, Testai FD.
Citation:
Efficacy and Safety of Using Dual Versus Monotherapy Antiplatelet Agents in Secondary Stroke Prevention: Systematic Review and Meta-Analysis of Randomized Controlled Clinical Trials. Circulation 2021;Apr 30:[Epub ahead of print].
Summary By:
Mollie McDermott, MD, MS

Quick Takes

  • After minor ischemic stroke, short-term (<30 days) dual antiplatelet therapy (DAPT) is superior to antiplatelet monotherapy (MAPT) in preventing recurrent stroke.
  • The results of this study suggest that short-term DAPT post-stroke should consist of aspirin and clopidogrel given its superior risk/benefit profile.
  • There is no role for long-term DAPT for secondary stroke prevention in most patients.

Study Questions:

With particular attention to short-term (≤30 days) versus long-term (>30 days) treatment after minor stroke, is dual antiplatelet therapy (DAPT) associated with a decreased risk of recurrent stroke when compared to antiplatelet monotherapy (MAPT)?

Methods:

This is a systematic review and meta-analysis. Eligible studies were randomized controlled trials that enrolled patients with mild to moderate acute ischemic stroke or transient ischemic attack (TIA) who were randomized within 3 days of symptom onset to receive either MAPT or DAPT. Of 1,515 studies screened, 17 studies (enrolling 27,358 patients) met inclusion criteria. The primary outcome was rate of stroke recurrence as defined by each trial.

Results:

For treatment duration of ≤30 days, DAPT was associated with a reduction of 20 (95% confidence interval [CI], 10-40) strokes per 1,000 people and two (95% CI, 1-4) additional major hemorrhages per 1,000 people. For treatment duration of >30 days, DAPT was associated with a reduction of 10 (95% CI, 0-30) strokes per 1,000 people and six (95% CI, 2-9) additional major hemorrhages per 1,000 people. For treatment duration of ≤30 days, aspirin plus ticagrelor but not aspirin plus clopidogrel was associated with an increased risk of major hemorrhage compared to MAPT.

Conclusions:

After minor ischemic stroke, short-term (≤30 days) DAPT is superior to MAPT in preventing recurrent stroke. The results of this study suggest that short-term DAPT post-stroke should consist of aspirin and clopidogrel given its superior risk/benefit profile.

Perspective:

The results of this study will not change management, as American Heart Association/American Stroke Association guidelines already support the use of DAPT with aspirin and clopidogrel started within 24 hours and continued for 21 days for patients presenting with minor ischemic stroke (Powers WJ, et al., Stroke 2019;50:e344-418).

Clinical Topics: Prevention, Vascular Medicine

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


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