Dual Antiplatelet Therapy Versus Aspirin in Patients With Stroke or Transient Ischemic Attack: Meta-Analysis of Randomized Controlled Trials

Abstract

Background and Purpose: Antiplatelet therapy is key for preventing thrombotic events after transient ischemic attack or ischemic stroke. Although the role of aspirin is well established, there is emerging evidence for the role of short-term dual antiplatelet therapy (DAPT) in preventing recurrent stroke. Methods: We conducted a systematic review and study-level meta-analyses of randomized controlled trials comparing outcomes of early initiation of short-term DAPT (aspirin+P2Y12 inhibitor for up to 3 months) versus aspirin alone in patients with acute stroke or transient ischemic attack. Primary efficacy outcome was risk of recurrent stroke and primary safety outcome was incidence of major bleeding. Secondary outcomes studied were risk of any ischemic stroke, hemorrhagic stroke, major adverse cardiovascular events, and all-cause death. Pooled risk ratios (RRs) and CIs were calculated using a random-effects model. Results: Four trials with a total of 21 459 patients were included. As compared to aspirin alone, DAPT had a lower risk of recurrent stroke (RR, 0.76 [95% CI, 0.68–0.83]; P <0.001; I 2 = 0%) but a higher risk of major bleeding events (RR, 2.22 [95% CI, 1.14–4.34], P =0.02, I 2 = 46.5%). Patients receiving DAPT had a lower risk of major adverse cardiovascular events (RR, 0.76 [95% CI, 0.69–0.84], P <0.001, I 2 = 0%) and recurrent ischemic events (RR, 0.74 [95% CI, 0.67–0.82], P <0.001, I 2 = 0%). Conclusions: As compared to aspirin alone, short-term DAPT within 24 hours of high-risk transient ischemic attack or mild-moderate ischemic stroke reduces the risk of recurrent stroke at the expense of higher risk of major bleeding.

Health outcomes after acute ischemic stroke:retrospective and survival analysis from Oman

“… 27 The majority of the patients were prescribed dual antiplatelets, which reflects adherence to the current recommendation of acute ischemic stroke management. 28 …”

Dual vs. mono antiplatelet therapy for acute ischemic stroke or transient ischemic attack with evidence of large artery atherosclerosis

“…This study is consonant with and extends prior investigations. Several trials and meta-analyses have demonstrated an advantage of short courses of DAPT over MAPT early after index event among patients with a broad range of non-cardioembolic stroke mechanisms, including large artery atherosclerosis, small vessel disease, and cryptogenic stroke ( 4 , 6 , 17 ). However, to our knowledge, this is the first meta-analysis elucidating the role of DAPT specifically in patients with symptomatic LAA.…”

Does prior use of antiplatelet therapy modify the effect of dual antiplatelet therapy in transient ischaemic attack/minor ischaemic stroke: A systematic review and meta‐analysis

“…Our search was limited to dates not included in this review (July 2020 onwards). The systematic review by Bhatia et al provided a comprehensive analysis comparing the outcomes of early initiation of short‐term dual antiplatelet therapy versus aspirin alone in patients with acute stroke or TIA [2]. The PubMed and Embase databases were systematically searched from July 2020 to 27 December 2021.…”

“…To reduce research waste data were extracted from a recent metaanalysis of dual versus single antiplatelet therapy in acute minor ischaemic stroke or TIA [2,7]. It was considered of sufficiently high quality to avoid the need to repeat it.…”

“…Dual antiplatelet therapy is recommended for acute management of non‐cardioembolic minor ischaemic stroke and high risk transient ischaemic attack (TIA) within 24 h and at least within 7 days from symptom onset, on the basis of clinical trials and meta‐analyses that have demonstrated a lower rate of subsequent stroke compared with single antiplatelet therapy [1, 2]. A number of clinical factors have been shown to influence effectiveness, including time from symptom onset to initiation of dual antiplatelet therapy [3].…”