Optimal Duration of Aspirin Plus Clopidogrel After Ischemic Stroke or Transient Ischemic Attack

Abstract

Background and Purpose— The role of aspirin plus clopidogrel (A+C) therapy compared with aspirin monotherapy in patients presenting with acute ischemic stroke (IS) or transient ischemic attack remains uncertain. We conducted this study to determine the optimal period of efficacy and safety of A+C compared with aspirin monotherapy. Methods— Ten randomized controlled trials (15 434 patients) were selected using MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) (inception June 2018) comparing A+C with aspirin monotherapy in patients with transient ischemic attack or IS. The primary efficacy outcome was recurrent IS, and the primary safety outcome was major bleeding. The secondary outcomes were major adverse cardiovascular events (composite of stroke, myocardial infarction, and cardiovascular mortality) and all-cause mortality. We stratified analysis based on the short- (≤1 month), intermediate- (≤3 month), and long-term (>3 month) A+C therapy. Effects were estimated as relative risk (RR) with 95% CI. Results— A+C significantly reduced the risk of recurrent IS at short-term (RR, 0.53; 95% CI, 0.37–0.78) and intermediate-term (RR, 0.72; 95% CI, 0.58–0.90) durations. Similarly, major adverse cardiovascular event was significantly reduced by short-term (RR, 0.68; 95% CI, 0.60–0.78) and intermediate-term (RR, 0.76; 95% CI, 0.61–0.94) A+C therapy. However, long-term A+C did not yield beneficial effect in terms of recurrent IS (RR, 0.81; 95% CI, 0.63–1.04) and major adverse cardiovascular events (RR, 0.87; 95% CI, 0.71–1.07). Intermediate-term (RR, 2.58; 95% CI, 1.19–5.60) and long-term (RR, 1.87; 95% CI, 1.36–2.56) A+C regimens significantly increased the risk of major bleeding as opposed to short-term A+C (RR, 1.82; 95% CI, 0.91–3.62). Excessive all-cause mortality was limited to long-term A+C (RR, 1.45; 95% CI, 1.10–1.93). Conclusions— Short-term A+C is more effective and equally safe in comparison to aspirin alone in patients with acute IS or transient ischemic attack.

Antiplatelet Therapy in the Secondary Prevention of Non-cardioembolic Ischemic Stroke and Transient Ischemic Attack: A Mini-Review

“…A combination of aspirin and clopidogrel seems to be beneficial not only shortly (24 h to 1 week) after an acute non-cardioembolic stroke, most often a minor ischemic stroke, or a high-risk TIA ( 24 ) but also throughout the first 90 days after the event ( 14 , 23 , 27 ). These findings have also been confirmed by other studies ( 30 , 31 ). Rahman et al ( 30 ) stated that DAPT with aspirin and clopidogrel significantly reduced the risk of recurrent IS in the short-term (RR, 0.53; 95% CI, 0.37–0.78) and intermediate-term (RR, 0.72; 95% CI, 0.58–0.90).…”

Ischemic stroke with a preceding Trans ischemic attack (TIA) less than 24 hours and thrombolytic therapy

“…The presence of a focal lesion on Diffusion-weighted magnetic resonance imaging (DW-MRI) is an important factor in the classification of TIA [12][13][14][15], and represents a contraindication for rtPA therapy [16]. The new tissue-based description of a TIA as a transient episode of neurological dysfunction without acute infarction is not a contraindication for rtPA in TIA-ischemic stroke patients [17].…”

Ischemic stroke with a preceding Trans ischemic attack(TIA) less than 24 hours: Predicting clinical risk factors for thrombolytic therapy

“…The presence of a focal lesion on DW-MRI is an important factor in the classification of transitory focal neurological dysfunction as a TIA [12][13][14][15], and represents a contraindication for rtPA therapy [16]. The new tissue-based description of a TIA as a transient episode of neurological dysfunction without acute infarction is not a contraindication for rtPA in TIA-ischemic stroke patients [17].…”