Antiplatelet therapy is key to prevent thrombotic events after a transient ischemic attack (TIA) or ischemic stroke. The role of aspirin is well established in this scenario, but there is emerging evidence for a short period of dual antiplatelet therapy (DAPT). Now, can this strategy avoid recurrent strokes without paying a price in terms of bleeding?
To answer this question, authors conducted a meta-analysis, published in STROKE, including all randomized studies comparing early start of short-term of dual antiplatelet therapy (up to 3 months) with aspirin plus a P2Y12 receptor inhibitor vs. aspirin alone in patients with stroke or transient ischemic attack.
The primary endpoint was risk of recurrent stroke, and the primary safety endpoint was major bleeding. Secondary endpoints included any stroke, hemorrhagic stroke, major cardiovascular event, and all-cause death.
Four large trials with a total of over 20,000 patients were included.
Dual antiplatelet therapy significantly lowered the risk of recurrent stroke (risk ratio [RR]: 0.76; 95% confidence interval [CI]: 0.68-0.83; p < 0.001). Its price? The rates for major bleeding doubled (RR: 2.22; 95% CI: 1.14–4.34; p = 0.02).
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Patients receiving DAPT also had a significantly lower risk of cardiovascular events (RR: 0.76; 95% CI: 0.69–0.84; p < 0.001), and of recurrent ischemic events (RR: 0.74; 95% CI: 0.67–0.82; p < 0.001).
Conclusion
Dual antiplatelet therapy for no more than 3 months prescribed within 24 hours of a high-risk transient ischemic attack or a mild to moderate stroke significantly lowers the risk of recurrent strokes compared with aspirin alone. The cost is a significant increase in major bleeding.
We need more evidence to adequately select which patients may derive a benefit.
Título original: Dual Antiplatelet Therapy Versus Aspirin in Patients With Stroke or Transient Ischemic Attack. Meta-Analysis of Randomized Controlled Trials.
Referencia: Kirtipal Bhatia et al. Stroke. 2021 Apr 27;STROKEAHA120033033. doi: 10.1161/STROKEAHA.120.033033.
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