Dual antiplatelet therapy vs monotherapy for stroke: which is better?

  • Hao Q & al.
  • BMJ
  • 18 Dec 2018

  • curated by Sarfaroj Khan
  • UK Clinical Digest
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Takeaway

  • Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin given within 24 hours after high-risk transient ischaemic attack (TIA) or acute ischaemic stroke reduces the risk for subsequent stroke by 2% with few serious adverse events.
  • Discontinuation of dual antiplatelet therapy within 21 days, and possibly as early as 10 days, of initiation is likely to maximise benefit and minimise harms.

Why this matters

  • Current guidelines for the management of acute ischaemic stroke and TIA typically recommend single antiplatelet therapy, most commonly aspirin.

Study design

  • 3 randomised controlled trials including 10,447 patients with acute minor ischaemic stroke or TIA attack met eligibility criteria after a search across electronic databases.
  • Funding: None.

Key results

  • Compared with aspirin alone, DAPT reduced the risk for any non-fatal recurrent stroke (relative risk [RR], 0.70; 95% CI, 0.61-0.80) and all recurrent stroke (RR, 0.71; 95% CI, 0.63-0.82).
  • Pooled analysis showed that DAPT possibly increased the risk for moderate or major extracranial haemorrhage (RR, 1.71; 95% CI, 0.92-3.20).
  • Kaplan-Meier curves up to days 10, 11 to 21 and 22 to 90 showed that DAPT reduced the risk for stroke in the first 10 days (OR, 0.64; 95% CI, 0.55-0.76); there was no appreciable additional benefit in days 22 to 90 (OR, 1.47; 95% CI, 0.84-2.56).

Limitations

  • Loading dose and treatment onset time differed among studies.

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