From the Guidelines
Dual Antiplatelet Therapy (DAPT) in Acute Ischemic Stroke Dual antiplatelet treatment (DAPT) with aspirin and clopidogrel is recommended for a limited duration in patients with acute ischemic stroke, specifically those with a high-risk of recurrence, such as those with minor stroke or transient ischemic attack (TIA) due to atherosclerotic disease 1.
Key Points
- The typical regimen consists of aspirin 50-100 mg daily and clopidogrel 75 mg daily, initiated within 24 hours of stroke onset and continued for 21 days 1.
- After this period, monotherapy with aspirin 50-100 mg daily or clopidogrel 75 mg daily is recommended for long-term secondary prevention 1.
- DAPT is not recommended for all patients with acute ischemic stroke, as the benefits must be weighed against the increased risk of bleeding complications 1.
- Patients with cardioembolic stroke, such as those with atrial fibrillation, should receive anticoagulation rather than DAPT 1.
Considerations
- The risk of bleeding should be considered and weighed against the potential benefits of DAPT when initiated early after onset 1.
- The optimal duration of DAPT to maximize the risk-benefit ratio is not fully established, with studies suggesting 21 to 90 days 1.
- Further research is needed to determine the optimal combination of medications, timing of initiation, and duration of DAPT, as well as the effectiveness and potential harm of DAPT among specific subgroups of patients 1.
From the Research
Role of Dual Antiplatelet Therapy in Acute Ischemic Stroke
- Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor (such as clopidogrel or ticagrelor) has been shown to reduce the risk of recurrent stroke in patients with acute ischemic stroke or transient ischemic attack (TIA) 2, 3, 4, 5.
- The use of DAPT for a limited time (up to 21-30 days) is recommended after minor noncardioembolic stroke, as it decreases the risk of recurrent stroke and composite events compared with monotherapy 2, 6.
- However, DAPT is associated with an increased risk of major bleeding, particularly when used for an extended period or with certain combinations of medications (such as aspirin and ticagrelor) 2, 3, 4, 5.
Efficacy of DAPT in Reducing Recurrent Stroke
- Studies have consistently shown that DAPT reduces the risk of recurrent stroke by 20-30% compared with aspirin alone 3, 4, 5.
- The benefit of DAPT is most pronounced when initiated within 24 hours of symptom onset and continued for a short duration (up to 21-30 days) 3, 6, 4.
Safety of DAPT
- The increased risk of major bleeding associated with DAPT is a significant concern, particularly when used for an extended period or with certain combinations of medications 2, 3, 4, 5.
- However, the absolute risk of major bleeding is relatively low, and the benefits of DAPT in reducing recurrent stroke may outweigh the risks in certain patient populations 3, 4, 5.