Guidance on dual antiplatelet therapy after high-risk TIA or minor ischaemic stroke

  • Uchino K
  • Ann Intern Med
  • 16 Apr 2019

  • curated by Pavankumar Kamat
  • UK Clinical Digest
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  • An international expert panel strongly favours initiating dual antiplatelet therapy (DAPT) of clopidogrel plus aspirin instead of aspirin alone within 24 hours of a high-risk transient ischaemic attack (TIA) or minor ischaemic stroke and continuing dual therapy for a duration of 10 to 21 days.

Why this matters

  • Evidence from individual trials as well as the systematic review and meta-analysis indicates a lower risk for ischaemic stroke recurrence with early administration of DAPT after stroke or TIA.
  • The optimal duration of DAPT therapy was determined based on the risk-benefit ratio of early DAPT administration.

Study design

  • Recommendations made by an international expert panel based on findings of a systematic review and meta-analysis of 3 randomised controlled trials comparing aspirin plus clopidogrel vs aspirin alone in patients (n=10,447; mean age, 62-68 years) with minor ischaemic stroke or high-risk TIA admitted ≤24 hours after symptom onset.
  • Minor ischaemic stroke is defined as the National Institutes of Health Stroke Scale score ≤3 and high-risk TIA is defined as ABCD2 scale score ≥4.
  • The panel comprised general internists, stroke neurologists, patients and caregivers, geriatricians, methodologists, critical care physicians, vascular surgeons, nurses and physiotherapists.
  • Funding: None.

Key results

  • Two key recommendations were made by the expert panel.
    1. DAPT with clopidogrel plus aspirin rather than single-agent therapy should be started ≤24 hours after the index TIA or stroke.
    2. DAPT should be administered for 10 to 21 days rather than >21 days after the index TIA or stroke.
  • The first recommendation is based on findings from the systematic review which showed a relative risk reduction (RRR) of 30% (95% CI, 20-39%) for recurrent non-fatal stroke, RRR of 10% (95% CI, -1 to 19%) for non-fatal functional disability and RRR of 19% (95% CI, -1 to 34%) for poor quality-of-life with DAPT vs aspirin alone.
  • This second recommendation is based on findings from a pooled analysis which showed that the benefit of DAPT did not outweigh risk beyond 21 days.


  • Patients with planned surgical interventions, who presented days or weeks after stroke, or those with large and severe strokes were not included.