- 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.
- 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).
- 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.
- 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.