Short-term dual antiplatelet therapy likely best for minor stroke, TIA

  • Pan Y & al.
  • JAMA Neurol
  • 19 Aug 2019

  • International Clinical Digest
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Takeaway

  • Among patients with minor stroke or high-risk transient ischaemic attack (TIA), discontinuing dual clopidogrel (Plavix)-aspirin antiplatelet therapy within 21 days may maximise benefit while minimising harms.

Why this matters

  • Optimal duration of dual antiplatelet therapy is unknown.

Key results

  • Vs aspirin alone, clopidogrel-aspirin reduced 90-day major ischemic events (6.5% vs 9.1%; HR, 0.70; P<.001>
  • Benefit:
    • Significant during 0-21 days (5.2% vs 7.8%; HR, 0.66; P<.001>
    • Not significant during 22-90 days (1.4% vs 1.5%; HR, 0.94; P=.72).
  • Pattern consistent across trials, subgroups.
  • Further analysis suggested benefit possibly restricted to 0-10 days (HR, 0.65; P<.001>
  • 90-day major haemorrhages nonsignificantly higher with clopidogrel-aspirin (HR, 1.59; P=.12).

Study design

  • Pooled analysis of individual patient data from randomised controlled trials, clopidogrel-aspirin vs aspirin, started 12-24 hours after minor stroke/high-risk TIA for secondary prevention:
  • Main outcomes: major ischaemic events (ischaemic stroke, myocardial infarction, fatal ischaemic vascular events), major haemorrhage.
  • Funding: Ministry of Science and Technology of People’s Republic of China; National Institute of Neurological Disorders and Stroke; Sanofi; others.

Limitations

  • Differing trial designs.
  • Therapy limited to 21 days in CHANCE.
  • Risk-benefit profile not assessed by stroke/TIA mechanism.
  • Statistical analysis not preplanned.

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