#291 Early dual antiplatelet therapy after minor stroke: Does it take two to tango?
CLINICAL QUESTION
In acute non-cardioembolic minor ischemic stroke or transient ischemic attack, does adding a second antiplatelet to ASA reduce recurrent stroke?
BOTTOM LINE
Compared to ASA alone, clopidogrel plus ASA reduced the risk of stroke from 8.2% to 5.5% but increased the risk of major bleeds from 0.6% to 1.2% at 21 days. Continuing clopidogrel beyond 21 days increased major bleeds without reducing strokes. There is no evidence that ticagrelor is more efficacious in reducing stroke than clopidogrel.
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EVIDENCE
- Clopidogrel + ASA versus ASA: Time analysis from meta-analysis1 of 3 randomized controlled trials (RCTs), 10,447 patients:
- Clopidogrel (300-600mg on day 1, then 75mg/day) plus ASA within 12-24 hours of onset of minor ischemic stroke or high-risk TIA versus ASA alone for 21-90 days, followed by single antiplatelet.
- At 21 days:
- Ischemic stroke: 5.5% versus 8.2% (ASA), number needed to treat (NNT)=38.
- Major bleed: 1.2% versus 0.6% (ASA) (number needed to harm [NNH]=167)
- On days 22-90:1,2
- Ischemic stroke: No difference.
- Major bleed: 0.6% versus 0.3% (ASA), NNH=334.
- Ticagrelor + ASA versus ASA: One RCT, 11,016 patients:3
- Started ticagrelor (180mg on day 1, then 90mg twice daily) plus ASA within 24 hours of mild-moderate ischemic stroke or TIA versus ASA alone, continued for 30 days.
- Ischemic stroke: Ticagrelor + ASA 5.0%, ASA 6.3%, NNT=84.
- Moderate-severe bleed: 0.65% versus 0.2%, NNH~200
- Intracranial hemorrhage: 0.36% versus 0.11%, NNH~330.
- Started ticagrelor (180mg on day 1, then 90mg twice daily) plus ASA within 24 hours of mild-moderate ischemic stroke or TIA versus ASA alone, continued for 30 days.
- No significant differences in disability or death between dual and single antiplatelet.1
- “Minor” stroke defined based on the National Institutes of Health Stroke Scale ≤3-5.1-4
- Cardioembolic strokes (e.g. related to atrial fibrillation) are treated differently.5
- Recurrent stroke risk highest within ~2 weeks of event.1,2,4
- Guidelines recommend clopidogrel + ASA for 21 days in patients with acute non-cardioembolic minor ischemic stroke.5
- Clopidogrel or ticagrelor alone have similar efficacy to ASA alone in minor-moderate ischemic non-cardioembolic stroke.6,7
- In acute coronary syndromes, ticagrelor + ASA causes more major bleeding and dyspnea (NNH 16) than clopidogrel + ASA.8
- Costs per 90 days: ASA $5, clopidogrel $40, ticagrelor $320.9
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Good info to have
Helpful article
new knowledge that Clopidogrel is more effective than Ticraglor for this condition
excellent
I would like to see ASA versus clopidogrel as single antiplatelet therapy compared in efficacy of reducing stroke /TIA over longer periods of time. Some of my patients stay on clopidogrel for years and would like to know whether and when to stop antiplatelet therapy
really helpful as we see alot of tia in GP land