Efficacy and safety of short-term dual- versus mono-antiplatelet therapy in patients with ischemic stroke or TIA: a meta-analysis of 10 randomized controlled trials

Yang, Liu; Fei, Zhaoxia; Wang, Wei; Fang, Jingxue; Zou, Meijuan; Cheng, Gang

doi:10.1007/s00415-016-8260-7

Cited by 7 publications

(5 citation statements)

References 33 publications

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“…Our review has important strengths compared with previous reviews. 22 34 35 36 37 We focused on a specific population, used the GRADE approach to establish quality of evidence, chose an analytical strategy that clearly separated mortal and morbid events, obtained data from authors that allowed implementation of this plan, and conducted an innovative analysis that documented the duration of intervention effects. Most importantly, we included the recent POINT study conducted in heterogeneous Western populations with its striking replication of the previous Chinese CHANCE study.…”

Section: Discussionmentioning

confidence: 99%

Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis

Qin

Tampi

O’Donnell

et al. 2018

BMJ

121

105

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ObjectiveTo assess the effectiveness and safety of dual agent antiplatelet therapy combining clopidogrel and aspirin to prevent recurrent thrombotic and bleeding events compared with aspirin alone in patients with acute minor ischaemic stroke or transient ischaemic attack (TIA).DesignSystematic review and meta-analysis of randomised, placebo controlled trials.Data sourcesMedline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Library, ClinicalTrials.gov, WHO website, PsycINFO, and grey literature up to 4 July 2018.Eligibility criteria for selecting studies and methodsTwo reviewers independently screened potentially eligible studies according to predefined selection criteria and assessed the risk of bias using a modified version of the Cochrane risk of bias tool. A third team member reviewed all final decisions, and the team resolved disagreements through discussion. When reports omitted data that were considered important, clarification and additional information was sought from the authors. The analysis was conducted in RevMan 5.3 and MAGICapp based on GRADE methodology.ResultsThree eligible trials involving 10 447 participants were identified. Compared with aspirin alone, dual antiplatelet therapy with clopidogrel and aspirin that was started within 24 hours of symptom onset reduced the risk of non-fatal recurrent stroke (relative risk 0.70, 95% confidence interval 0.61 to 0.80, I2=0%, absolute risk reduction 1.9%, high quality evidence), without apparent impact on all cause mortality (1.27, 0.73 to 2.23, I2=0%, moderate quality evidence) but with a likely increase in moderate or severe extracranial bleeding (1.71, 0.92 to 3.20, I2=32%, absolute risk increase 0.2%, moderate quality evidence). Most stroke events, and the separation in incidence curves between dual and single therapy arms, occurred within 10 days of randomisation; any benefit after 21 days is extremely unlikely.ConclusionsDual antiplatelet therapy with clopidogrel and aspirin given within 24 hours after high risk TIA or minor ischaemic stroke reduces subsequent stroke by about 20 in 1000 population, with a possible increase in moderate to severe bleeding of 2 per 1000 population. Discontinuation of dual antiplatelet therapy within 21 days, and possibly as early as 10 days, of initiation is likely to maximise benefit and minimise harms.

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Section: Discussionmentioning

confidence: 99%

Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis

Qin

Tampi

O’Donnell

et al. 2018

BMJ

121

105

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“…The DAPT use of aspirin+ticagrelor has not been addressed in previous meta-analyses. [20][21][22][23][24] A recent meta-analysis by Hao et al 21 that compared clopidogrel plus aspirin versus aspirin alone, when DAPT was started within 24 hours of symptom onset that demonstrated a reduced risk of nonfatal recurrent stroke, without an apparent impact on all-cause mortality but with a likely increase in moderate or severe extracranial bleeding. Our meta-analysis also included recently published data from the THALES trial, and we performed more sensitivity analyses (stratified by treatment regimen or duration, used effect size of HR, RD, and number needed to treat) to draw more robust conclusions about DAPT.…”

Section: Clinical and Population Sciencesmentioning

confidence: 99%

P2Y12 Inhibitors Plus Aspirin Versus Aspirin Alone in Patients With Minor Stroke or High-Risk Transient Ischemic Attack

Xiong

et al. 2021

Stroke

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Background and purpose: We performed a systemic review and meta-analysis to elucidate the effectiveness and safety of dual antiplatelet (DAPT) therapy with P2Y12 inhibitors (clopidogrel/ticagrelor) and aspirin versus aspirin monotherapy in patients with mild ischemic stroke or high-risk transient ischemic attack. Methods: Following Preferred Reported Items for Systematic Review and Meta-Analysis standards for meta-analyses, Medline, Embase, Cochrane Central Register of Controlled Trials, and the Cochrane Library were searched for randomized controlled trials that included patients with a diagnosis of an acute mild ischemic stroke or high-risk transient ischemic attack, intervention of DAPT therapy with clopidogrel/ticagrelor and aspirin versus aspirin alone from January 2012 to July 2020. The outcomes included subsequent stroke, all-cause mortality, cardiovascular death, hemorrhage (mild, moderate, or severe), and myocardial infarction. A DerSimonian-Laird random-effects model was used to estimate pooled risk ratio (RR) and corresponding 95% CI in R package meta. We assessed the heterogeneity of data across studies with use of the Cochran Q statistic and I 2 test. Results: Four eligible trials involving 21 493 participants were included in the meta-analysis. DAPT therapy started within 24 hours of symptom onset reduced the risk of stroke recurrence by 24% (RR, 0.76 [95% CI, 0.68–0.83], I 2 =0%) but was not associated with a change in all-cause mortality (RR, 1.30 [95% CI, 0.90–1.89], I 2 =0%), cardiovascular death (RR, 1.34 [95% CI, 0.56–3.17], I 2 =0%), mild bleeding (RR, 1.25 [95% CI, 0.37–4.29], I 2 =94%), or myocardial infarction (RR, 1.45 [95% CI, 0.62–3.39], I 2 =0%). However, DAPT was associated with an increased risk of severe or moderate bleeding (RR, 2.17 [95% CI, 1.16–4.08], I 2 =41%); further sensitivity tests found that the association was limited to trials with DAPT treatment duration over 21 days (RR, 2.86 [95% CI, 1.75–4.67], I 2 =0%) or ticagrelor (RR, 2.17 [95% CI, 1.16–4.08], I 2 =37%) but not within 21 days or clopidogrel. Conclusions: In patients with noncardioembolic mild stroke or high-risk transient ischemic attack, DAPT with aspirin and clopidogrel/ticagrelor is more effective than aspirin alone for recurrent stroke prevention with a small absolute increase in the risk of severe or moderate bleeding.

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“…Aspirin is the preferred antiplatelet agent, and all patients are recommended immediate treatment with aspirin 300 mg/d 16,22,23 . The combination of aspirin and clopidogrel is widely used based on findings from some recent studies [24][25][26][27] , but the duration of clopidogrel use is unclear. Addition of clopidogrel 75 mg/d for a short term (21-30 days) is considered better than intermediate term (<3 months), as it gives the same benefit as intermediate term with lower bleeding risk 22,[28][29][30][31][32][33][34] .…”

Section: Management Of Tia Has Changedmentioning

confidence: 99%

The changing face of transient ischaemic attacks

Mettananda

Ranawaka

2020

J of Cey Coll of Phy

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TIAs predict stroke risk A transient ischaemic attack (TIA) is not a simple 'mini-stroke', but a major warning sign of an impending stroke that demands urgent attention. About 15-30% of all ischaemic strokes are preceded by TIAs 1-4. The estimated recurrent TIA and stroke risk at three months after a TIA is 17.3% 1 ; the risk of stroke is greatest immediately after a TIA, providing only a short window of opportunity for stroke prevention 2. 52% of all strokes during the first 7 days and 42% of all strokes during the first 30 days following a TIA do occur within the first 24 hours 2-5. Early and optimal treatment of TIA has been shown to be effective in prevention of recurrent The changing face of transient ischaemic attacks This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Efficacy and safety of short-term dual- versus mono-antiplatelet therapy in patients with ischemic stroke or TIA: a meta-analysis of 10 randomized controlled trials

Cited by 7 publications

References 33 publications

Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis

Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis

P2Y12 Inhibitors Plus Aspirin Versus Aspirin Alone in Patients With Minor Stroke or High-Risk Transient Ischemic Attack

The changing face of transient ischaemic attacks

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