What is the recommended Dual Antiplatelet Therapy (DAPT) regimen for a patient presenting with stroke or Transient Ischemic Attack (TIA)-like symptoms, with a National Institutes of Health Stroke Scale (NIHSS) less than 5 and an ABCD2 (Age, Blood Pressure, Clinical Features, Duration of symptoms, and Diabetes) score of 4 or more, and a negative Computed Tomography (CT) scan with a pending Magnetic Resonance Imaging (MRI) scan, within 24 hours of symptom onset, and what alternative antiplatelet agents, such as Aspirin (acetylsalicylic acid) and Plavix (clopidogrel), can be used if one fails?

From the Guidelines

For a patient presenting with stroke or TIA-like symptoms, with NIHSS <5, ABCD2 score ≥4, and a negative CT scan within 24 hours of symptom onset, the recommended DAPT regimen is aspirin 325 mg loading dose followed by 81 mg daily, plus clopidogrel 300-600 mg loading dose followed by 75 mg daily, as supported by the CHANCE trial and guidelines from the American Heart Association/American Stroke Association 1. This combination should be continued for 21 days, after which patients typically transition to a single antiplatelet agent for long-term secondary prevention.

• The choice of antiplatelet agent after 21 days should be based on the patient's individual risk factors and tolerability, with aspirin being a preferred option due to its lower bleeding risk compared to clopidogrel 1.
• If clopidogrel is contraindicated or ineffective, alternatives include ticagrelor (180 mg loading dose, then 90 mg twice daily) or the combination of aspirin plus extended-release dipyridamole (25/200 mg twice daily) 1.
• The pending MRI will help confirm the diagnosis and may influence the duration of DAPT, but treatment should not be delayed while awaiting imaging results.
• It is essential to note that the effectiveness of DAPT decreases with time, and the window for initiation can be extended up to 72 hours, but with reduced effectiveness 1.
• Proton pump inhibitors should be considered for patients at high risk of gastrointestinal bleeding.
• The short-term DAPT approach is based on evidence showing significant reduction in recurrent stroke risk in the first month after minor stroke or high-risk TIA, with the greatest benefit occurring in the first week 1.

From the Research

Patient Presentation and Initial Treatment

• A patient presents with stroke or Transient Ischemic Attack (TIA)-like symptoms, with a National Institutes of Health Stroke Scale (NIHSS) less than 5 and an ABCD2 score of 4 or more.
• The patient has a negative Computed Tomography (CT) scan and a pending Magnetic Resonance Imaging (MRI) scan.
• If the patient is within 24 hours of symptom onset, Dual Antiplatelet Therapy (DAPT) with aspirin and clopidogrel (Plavix) is recommended for 21 days, as supported by the POINT trial 2 and the updated systematic review and meta-analysis 3.

Extension of Treatment Window

• The treatment window for DAPT can be extended up to 72 hours, as suggested by the THALES trial 4 and the updated network meta-analysis 5, although the effectiveness of DAPT may decrease with time.

Comparison of Antiplatelet Agents

• Aspirin is associated with a lower bleeding risk compared to Plavix (clopidogrel) as monotherapy after 21 days, as indicated by the study 3.
• Ticagrelor (Brilinta) plus aspirin may be a considerable option for patients after a minor stroke or TIA, as suggested by the study 5 and the Bayesian network meta-analysis 6.
• If a patient fails Plavix, ticagrelor or dipyridamole plus aspirin may be alternative options, although the superiority of these alternatives is still being researched, as mentioned in the study 6.

Bleeding Risks and Outcomes

• DAPT is associated with a higher risk of bleeding, including intracranial bleeding and major bleeding, as reported in the studies 3, 4, and 2.
• The risk of bleeding should be carefully considered when selecting antiplatelet therapy, as highlighted by the studies 5 and 6.