Title:Clinical Effects of Dual Antiplatelet Therapy or Aspirin Monotherapy after Acute Minor Ischemic Stroke or Transient Ischemic Attack, a Meta-Analysis
Volume: 27
Issue: 40
Author(s): Francesco Condello, Gaetano Liccardo and Giuseppe Ferrante*
Affiliation:
- Department of Cardiovascular Medicine, Humanitas Research Hospital-IRCCS Via Manzoni, 56, 20089 Rozzano, Milan,Italy
Keywords:
Acute minor ischemic stroke, transient ischemic attack, aspirin, clopidogrel, ticagrelor, dual antiplatelet therapy, bleeding.
Abstract:
Background: Evidence about the use of dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitors
in patients with acute minor ischemic stroke or transient ischemic attack (TIA) is emerging. The aim of
our study was to provide an updated and comprehensive analysis about the risks and benefits of DAPT versus
aspirin monotherapy in this setting.
Methods: The PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov databases,
main international conference proceedings were searched for randomized controlled trials comparing DAPT
versus aspirin monotherapy in patients with acute ischemic stroke or TIA not eligible for thrombolysis or
thrombectomy presenting in the first 24 hours after the acute event. Data were pooled by meta-analysis using a
random-effects model. The primary efficacy endpoint was ischemic stroke recurrence, and the primary safety
outcome was major bleeding. Secondary endpoints were intracranial hemorrhage, hemorrhagic stroke, and allcause
death.
Results: A total of 4 studies enrolling 21,459 patients were included. DAPT with clopidogrel was used in 3
studies, DAPT with ticagrelor in one study. DAPT duration was 21 days in one study, 1 month in one study,
and 3 months in the remaining studies. DAPT was associated with a significant reduction in the risk of ischemic
stroke recurrence (relative risk (RR), 0.74; 95% confidence interval (CI), 0.67-0.82, P<0.001, number needed to
treat 50 (95% CI 40-72), while it was associated with a significantly higher risk of major bleeding (RR, 2.59;
95% CI 1.49-4.53, P=0.001, number needed to harm 330 (95% CI 149-1111), of intracranial hemorrhage (RR
3.06, 95% CI 1.41-6.66, P=0.005), with a trend towards higher risk of hemorrhagic stroke (RR 1.83, 95% CI
0.83-4.05, P=0.14), and a slight tendency towards higher risk of all-cause death (RR 1.30, 95% CI 0.89-1.89,
P=0.16).
Conclusion: Among patients with acute minor ischemic stroke or TIA, DAPT, as compared with aspirin monotherapy,
might offer better effectiveness in terms of ischemic stroke recurrence at the expense of a higher risk of
major bleeding. The trade-off between ischemic benefits and bleeding risks should be assessed in tailoring the
therapeutic strategies.
