From the Guidelines
Yes, dual antiplatelet therapy (DAPT) is recommended for high-risk transient ischemic attack (TIA) patients, specifically those with an ABCD2 score ≥4, initiated early (ideally within 12-24 hours of symptom onset) and continued for 21 to 90 days. The standard regimen consists of aspirin plus clopidogrel, which provides more comprehensive platelet inhibition than either agent alone, significantly reducing the risk of recurrent stroke during the high-risk period following a TIA 1. For patients with recent minor (NIHSS score ≤3) noncardioembolic ischemic stroke or high-risk TIA, DAPT should be initiated early and continued for 21 to 90 days, followed by single antiplatelet therapy (SAPT) 1.
Some key points to consider when prescribing DAPT for TIA patients include:
- The benefits of DAPT in reducing recurrent ischemic stroke should be weighed against the potential risks of bleeding, particularly in patients with a history of bleeding or those taking other medications that increase the risk of bleeding 1.
- The optimal duration of DAPT to maximize the risk-benefit ratio is 21 to 90 days, as continuous use of DAPT for >90 days or the use of triple antiplatelet therapy is associated with excess risk of hemorrhage 1.
- Patients with high-risk features such as symptomatic carotid stenosis or those with multiple TIAs may benefit from DAPT, but the decision to initiate DAPT should be individualized based on the patient's specific risk factors and medical history 1.
Overall, DAPT is a recommended treatment for high-risk TIA patients, but the duration and risks should be carefully considered on a case-by-case basis.
From the Research
Dual Antiplatelet Therapy (DAPT) for Transient Ischemic Attack (TIA)
- DAPT with clopidogrel and aspirin may provide greater protection against subsequent stroke than monotherapy in patients with TIA or ischemic stroke 2.
- Short-duration DAPT (≤ 1 month) started during the early acute ischemic phase is associated with less bleeding than longer DAPT and greater reduction of recurrent strokes compared with monotherapy 2.
- DAPT had a lower risk of recurrent stroke (RR, 0.76; 95% CI, 0.68–0.83) but a higher risk of major bleeding events (RR, 2.22; 95% CI, 1.14–4.34) compared to aspirin alone 3.
Comparison of DAPT Regimens
- Both clopidogrel and aspirin (HR, 0.74; 95% CrI, 0.65-0.84) and ticagrelor and aspirin (HR, 0.79; 95% CrI, 0.68-0.91) were superior to aspirin in the prevention of recurrent stroke and death 4.
- There was no statistically significant difference between clopidogrel and aspirin compared with ticagrelor and aspirin (HR, 0.94; 95% CrI, 0.78-1.13) 4.
Duration and Safety of DAPT
- Short-term dual DAPT of 3-6 months, or even 1 month in high-bleeding risk patients, is equivalent in terms of efficacy and effectiveness compared to long-term DAPT for patients who experienced percutaneous coronary intervention in an acute coronary syndrome setting 5.
- Prolonged DAPT beyond 12 months reduces stent thrombosis, major adverse cardiovascular events, and myocardial infarction rates but increases bleeding risk 5.
- The combination of aspirin and clopidogrel is more hazardous than clopidogrel alone in patients with recent TIA and ischemic stroke, but may have a role immediately after TIA and ischemic stroke in patients with symptomatic large artery atherothromboembolism 6.