From the Guidelines
For patients with high stroke risk after a TIA or minor ischemic stroke, dual antiplatelet therapy (DAPT) with aspirin 81-325 mg daily plus clopidogrel 75 mg daily is recommended for 21-90 days, followed by single antiplatelet therapy long-term, as supported by the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack 1. This approach is based on the benefits of reducing recurrent ischemic stroke, as shown in a systematic review for the 2021 guideline, which found that DAPT is more effective than single antiplatelet therapy (SAPT) for early secondary stroke prevention when initiated soon after high-risk TIA or minor stroke 1. Key considerations include:
- Initiating DAPT early, ideally within 12-24 hours of symptom onset, for patients with recent minor noncardioembolic ischemic stroke or high-risk TIA (ABCD2 score ≥4) 1.
- Continuing DAPT for 21 to 90 days, as this duration has been associated with a reduced risk of recurrent ischemic stroke without a significant increase in bleeding risk 1.
- Switching to single antiplatelet therapy after the short-term DAPT period, as long-term DAPT is not recommended due to the increased risk of bleeding events 1.
- Managing vascular risk factors and implementing lifestyle modifications to further reduce the risk of recurrent stroke and improve overall outcomes 1.
From the Research
Dual Antiplatelet Therapy with ABCD Score
When considering dual antiplatelet therapy for patients with a high risk of stroke after a Transient Ischemic Attack (TIA) or minor ischemic stroke, several factors come into play. The ABCD score is a tool used to predict the risk of stroke in patients who have had a TIA.
- The ABCD score takes into account factors such as age, blood pressure, clinical features, duration of symptoms, and diabetes to predict the risk of stroke 2.
- Dual antiplatelet therapy (DAPT) with a P2Y12 inhibitor (such as clopidogrel or ticagrelor) and aspirin has been shown to reduce the risk of recurrent stroke in patients with minor ischemic stroke or high-risk TIA 3, 2, 4, 5.
- However, DAPT also increases the risk of bleeding, particularly severe or moderate bleeding 2, 4, 5.
- The decision to use DAPT should be based on the individual patient's risk of stroke and bleeding, as well as other factors such as renal function and concomitant medications 6.
Recommendations for Dual Antiplatelet Therapy
- For patients with a high risk of stroke after a TIA or minor ischemic stroke, DAPT with a P2Y12 inhibitor and aspirin may be recommended for a short period of time (e.g. 21 days) to reduce the risk of recurrent stroke 2, 4.
- The choice of P2Y12 inhibitor (clopidogrel or ticagrelor) should be based on the individual patient's characteristics and risk factors 6, 5.
- Patients should be closely monitored for signs of bleeding and other adverse effects while on DAPT 2, 4, 5.
Considerations for Specific Patient Populations
- For patients with a history of stroke or TIA, prasugrel should be avoided due to an increased risk of cerebrovascular events 6.
- For patients older than 75 years or who weigh less than 60 kg, prasugrel should also be avoided due to an increased risk of bleeding 6.
- For patients with renal impairment, the dose of the P2Y12 inhibitor may need to be adjusted to minimize the risk of bleeding 6.