What is the recommended duration of Dual Antiplatelet Therapy (DAPT) for an acute stroke?

From the Guidelines

The recommended duration of Dual Antiplatelet Therapy (DAPT) for acute stroke is typically 21-30 days, after which patients should continue with single antiplatelet therapy long-term. The most common DAPT regimen consists of aspirin (81-325 mg daily) plus clopidogrel (75 mg daily), with a loading dose of clopidogrel (300-600 mg) often given at initiation, as supported by the 2023 systematic review and synthesis of global stroke guidelines 1. This short-term DAPT approach is specifically for non-cardioembolic ischemic strokes, particularly those classified as minor strokes or high-risk TIAs (transient ischemic attacks).

The American Heart Association/American Stroke Association guideline from 2021 also recommends that for patients with recent minor (NIHSS score ≤3) noncardioembolic ischemic stroke or high-risk TIA (ABCD2 score ≥4), DAPT (aspirin plus clopidogrel) should be initiated early and continued for 21 to 90 days, followed by single antiplatelet therapy (SAPT) 1. However, the most recent and highest quality evidence from the 2023 systematic review suggests a more specific duration of 21 days for DAPT in patients with minor ischemic stroke or high-risk TIA, after which long-term single antiplatelet therapy with aspirin or clopidogrel should be continued 1.

Key points to consider include:

• The initiation of DAPT as early as possible, ideally within 12-24 hours of symptom onset, after an intracranial hemorrhage is excluded on neuroimaging studies.
• The use of a single loading dose of aspirin and clopidogrel at the beginning of DAPT therapy.
• The recommendation for long-term single antiplatelet therapy after completing the short course of DAPT.
• The consideration of alternative DAPT regimens, such as aspirin plus ticagrelor, for patients with mild-moderate ischemic stroke or high-risk TIA.

Overall, the approach to DAPT in acute stroke aims to balance the early benefit of more aggressive platelet inhibition against the increased bleeding risk associated with prolonged DAPT, based on the evidence showing that the highest risk of recurrent stroke occurs in the first few weeks after the initial event 1.

From the Research

Recommended Duration of Dual Antiplatelet Therapy (DAPT) for Acute Stroke

The recommended duration of DAPT for acute stroke varies depending on the patient's condition and risk factors.

• For patients with minor ischemic stroke or high-risk transient ischemic attack, short-term DAPT (aspirin + P2Y12 inhibitor) for up to 3 months is recommended 2, 3.
• The use of DAPT beyond 3 months may result in substantial bleeding risks 4, 5.
• For long-term stroke prevention, aspirin-dipyridamole combination or aspirin/clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients 3.
• The treatment duration varies, but patients who have received stenting should receive at least 1 year of combination therapy 6.
• Understanding the perceived ischemic and bleeding risks for each individual patient is paramount in deciding targeted DAPT duration 5.

Considerations for DAPT Duration

• Short-duration DAPT (6 months or less) is acceptably safe when clinically necessary, though recent trials demonstrate non-significant trends towards increased risk of ischemic events with shorter durations 5.
• Extended-duration DAPT clearly confers a reduced risk of subsequent ischemic events but at an increased risk of bleeding 5.
• For patients at a higher bleeding risk with a low ischemic risk, short-duration DAPT (6 months) is acceptable 5.
• For patients with continued ischemic risk factors and a low bleeding risk, extended-duration DAPT (up to 30 months) is recommended 5.

Tools for Guiding DAPT Duration

• The PRECISE DAPT and DAPT prediction tools are helpful in making decisions about targeted DAPT duration 5.