When is Dual Antiplatelet Therapy (DAPT) used in a cerebrovascular accident (stroke)?

From the Guidelines

Dual antiplatelet therapy (DAPT) is recommended for patients with minor ischemic stroke or high-risk transient ischemic attack (TIA) within 24 hours of symptom onset, for a short duration of 21-30 days, followed by single antiplatelet therapy (SAPT) for long-term secondary prevention. This approach is based on the findings of recent studies, including the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1, which suggests that DAPT is more effective than SAPT for the reduction of recurrent ischemic stroke when initiated early after the onset of minor stroke or high-risk TIA. The standard regimen consists of aspirin 81-325 mg daily plus clopidogrel 75 mg daily (with a loading dose of 300-600 mg on day 1) for 21-30 days, followed by SAPT for long-term secondary prevention. Alternative DAPT combinations include aspirin plus ticagrelor 90 mg twice daily for 30 days.

The use of DAPT in this context is supported by several studies, including a systematic review and meta-analysis of trials that compared DAPT and SAPT for secondary stroke prevention 1. These studies found that DAPT was superior to SAPT for prevention of recurrent ischemic stroke, any recurrent stroke, and major adverse cardiac events (MACE) in people with minor stroke or high-risk TIA who were at low risk of bleeding. However, the meta-analysis also found a pooled increase in risk of major bleeding with DAPT compared to SAPT, highlighting the need to weigh the benefits and risks of DAPT in individual patients.

Some key points to consider when using DAPT in patients with minor ischemic stroke or high-risk TIA include:

• DAPT should not be used in hemorrhagic stroke or when there is significant risk of bleeding
• The duration of DAPT should be limited to 21-30 days, as longer durations are associated with an increased risk of bleeding without additional benefit
• The choice of DAPT regimen should be individualized based on patient factors, such as renal function and bleeding risk
• Patients should be closely monitored for signs of bleeding and other adverse effects during DAPT therapy.

Overall, the use of DAPT in patients with minor ischemic stroke or high-risk TIA is a complex decision that requires careful consideration of the benefits and risks in individual patients. However, based on the current evidence, DAPT is a recommended treatment option for patients with minor ischemic stroke or high-risk TIA within 24 hours of symptom onset, for a short duration of 21-30 days, followed by SAPT for long-term secondary prevention 1.

From the Research

Use of DAPT in Stroke

• DAPT is used in patients with acute non-cardioembolic minor ischemic stroke or high-risk transient ischemic attack to reduce the risk of recurrent stroke 2, 3, 4.
• The addition of a P2Y12 inhibitor (such as clopidogrel or ticagrelor) to aspirin has been shown to be effective in reducing the risk of stroke recurrence 2, 3, 4.
• DAPT is typically initiated within 24 hours of symptom onset and is usually continued for a short period of time (up to 3 months) 2, 3, 5.
• The use of DAPT is associated with an increased risk of major bleeding, particularly with ticagrelor and with treatment durations over 21 days 3, 4.

Patient Selection

• DAPT is recommended for patients with minor non-cardioembolic ischemic stroke or high-risk transient ischemic attack 2, 3, 4.
• Patients with large artery atherosclerosis may benefit from short-term DAPT with clopidogrel and aspirin 5.
• The use of DAPT in patients with intracranial atherosclerotic disease has also been assessed, showing a favorable profile compared to percutaneous angioplasty and stenting 6.

Treatment Duration and Bleeding Risk

• The optimal duration of DAPT treatment is still unclear, but most studies have used treatment durations of up to 3 months 2, 3, 5.
• The risk of major bleeding is higher with DAPT than with aspirin alone, particularly with ticagrelor and with treatment durations over 21 days 3, 4.
• The benefits of DAPT in reducing the risk of recurrent stroke must be weighed against the increased risk of bleeding 2, 3, 4.