Comparative Effectiveness of Dual Antiplatelet Therapy With Aspirin and Clopidogrel Versus Aspirin Monotherapy in Mild-to-Moderate Acute Ischemic Stroke According to the Risk of Recurrent Stroke

Abstract

Background: This study compared the effectiveness of dual antiplatelet therapy (DAPT) with clopidogrel-aspirin with that of aspirin monotherapy (AM) in mild-to-moderate acute ischemic stroke considering the risk of recurrent stroke using the Stroke Prognosis Instrument II (SPI-II) score. Methods: This study is a retrospective analysis of data from a prospective, nationwide, multicenter stroke registry database between January 2011 and July 2018. We included patients with mild-to-moderate (National Institutes of Health Stroke Scale score ≤10), acute (within 24 hours of onset), noncardioembolic ischemic stroke. The primary outcome was a 3-month composite of stroke (either hemorrhagic or ischemic), myocardial infarction, and all-cause mortality. Propensity scores using the inverse probability of treatment weighting method were used to mitigate baseline imbalances between the DAPT and AM groups and within each subgroup considering SPI-II scores. Results: Among the 15 430 patients (age, 66±13 years; men, 62.0%), 45.1% (n=6960) received DAPT and 54.9% (n=8470) received AM. Primary outcome events were significantly more frequent in the AM group (16.7%) than in the DAPT group (15.5%; P =0.03). Weighted Cox proportional hazards models showed a reduced risk of 3-month primary vascular events in the DAPT group versus the AM group (hazard ratio, 0.84 [0.78–0.92]; P <0.001), with no interaction between acute treatment type and SPI-II risk subgroups ( P interaction =0.44). However, among the high-risk patients with SPI-II scores >7, a substantially larger absolute benefit was observed for 3-month composite vascular events in the DAPT group (weighted absolute risk differences, 5.4%), whereas smaller absolute benefits were observed among patients in the low- or medium-risk SPI-II subgroups (1.7% and 2.4%, respectively). Conclusions: Treatment with clopidogrel-aspirin was associated with a reduction in 3-month vascular events compared with AM in mild-to-moderate acute noncardioembolic ischemic stroke patients. Larger magnitudes of the effects of DAPT with clopidogrel-aspirin were observed in the high-risk subgroup by SPI-II risk scores.

Dual versus mono antiplatelet therapy in mild‐to‐moderate stroke during hospitalization

“…It was observed that patients in higher NIHSS groups experienced primary events more frequently than those in lower subgroups 14 . In an analysis of comparative effectiveness of DAPT versus aspirin in mild‐to‐moderate (NIHSS ≤10), acute ischemic stroke using the Stroke Prognosis Instrument II score, 21 patients in the high‐risk subgroup (SPI‐II >7) had the highest proportion of DAPT and achieved the greatest benefits of DAPT than those in other subgroups. Patients with higher risk of vascular events were more likely to receive DAPT with clopidogrel‐aspirin than aspirin.…”

Dual Antiplatelet Therapy After an Acute Nonminor Stroke

“…5,6 Other observational studies examining DAPT in acute nonminor stroke have had varied results. Lee et al 12 examined the role of DAPT in an observational study that included 15 430 patients with mild-to-moderate stroke (NIHSS score ≤10) within 24 hours of symptom onset. The primary efficacy outcome was a 3-month composite of stroke, MI, and all-cause mortality.…”

The Efficacy and Safety of Cilostazol vs. Aspirin for Secondary Stroke Prevention: A Systematic Review and Meta-Analysis

“…Stroke is the most common cause of disabilities and death ( 3 ). Despite the efforts of researchers and pharmaceutical companies, the risk of stroke recurrence remains high ( 19 ). The use of antiplatelet agents is recommended to reduce the long-term risk of non-cardioembolic ischemic stroke or TIA ( 20 ).…”