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

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.