#109 Anti-platelets after stroke: Are two better than one?

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- Interpretation challenged by: inconsistent results, different endpoints, and different inclusion criteria.
- DP-ASA vs. ASA:
- Stroke: statistically significant relative risk reduction ~20% with combination.1,8
- Number Needed to Treat (NNT) 100 over 3.5 years.11
- No difference in major bleeds.1,5
- Discontinuation due to headache more common with DP-ASA.
- Number Needed to Harm (NNH) 16 over two years.12
- New Randomized Controlled Trial (RCT) showed increased stroke with DP-ASA, hazard ratio 1.52 (95% confidence interval: 1.01-2.29).13
- Stroke: statistically significant relative risk reduction ~20% with combination.1,8
- Clopidogrel + ASA vs. clopidogrel (one RCT):14
- Similar efficacy for stroke prevention.
- Major bleeds doubled with combination (NNH 76).
- Clopidogrel + ASA vs. ASA:
- Similar efficacy1,2 except:
- Recent Chinese RCT: possible reduced stroke5 (NNT 29 over 90 days) when clopidogrel added for 21 days in acute stroke.15
- Similar bleeding1,4-6 except:
- One RCT: Possible increased major bleeding (NNH 100) and death (NNH 142) over 3.4 years with combination.16
- Similar efficacy1,2 except:
- Clopidogrel vs. DP-ASA (one RCT):17
- Similar efficacy, less major bleeding with clopidogrel (NNH 200 over 2.5 years).
- ASA alone is effective, with statistically significant relative risk reduction in:1,18
- Stroke ~20%; estimated NNT 79 over 6-12 months.
- Major vascular events ~25%.
- Clopidogrel alone has similar efficacy to ASA alone in stroke.19
- Guidelines recommend either ASA, DP-ASA, or clopidogrel.20
- This reflects present evidence (and its inconsistency).
- Costs per 90 days: ASA $5, clopidogrel $71, DP-ASA $94.