Stroke: risk-benefit calculus favors limited-duration dual antiplatelet therapy

  • Rahman H & al.
  • Stroke
  • 11 Mar 2019

  • International Clinical Digest
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Takeaway

  • After ischemic stroke or transient ischemic attack, the risk-benefit calculus favors combination aspirin and clopidogrel (Plavix) over aspirin monotherapy only for the first postevent month.

Why this matters

  • AHA/ASA guidelines recommend 21 days of dual antiplatelet therapy, but trial results are mixed.

Key results

  • Compared with aspirin alone, aspirin-clopidogrel reduced risk for recurrent ischemic stroke:
    • Short term (relative risk [RR], 0.53; 95% CI, 0.37-0.78).
    • Intermediate term (RR, 0.72; 95% CI, 0.58-0.90).
  • Also reduced risk for major adverse cardiovascular events:
    • Short term (RR, 0.68; 95% CI, 0.60-0.78).
    • Intermediate term (RR, 0.76; 95% CI, 0.61-0.94).
  • Long-term reductions not significant.
  • Risk for major bleeding significantly higher with aspirin-clopidogrel:
    • Intermediate term (RR, 2.58; 95% CI, 1.19-5.60).
    • Long term (RR, 1.87; 95% CI, 1.36-2.56).
  • All-cause mortality elevated with long-term use (RR, 1.45; 95% CI, 1.10-1.93).

 Study design

  • Meta-analysis of 10 randomized controlled trials among 15,434 patients with acute ischemic stroke, transient ischemic attack.
  • Short term (≤1 month), intermediate term (>1 month to ≤3 months), long term (>3 months).
  • Main outcomes: recurrent ischemic stroke, major bleeding.
  • Funding: None disclosed.

Limitations

  • Variations in trial populations, treatment.
  • Influence of CYP2C19 variants not assessable.
  • Information lacking on preexisting use of antiplatelet agents, other medications.
  • Possible inadequate statistical power.