For a patient post non-hemorrhagic stroke on dual anti-platelet therapy (DAPT), which anti-platelet agent should be stopped and which one continued long-term?

Management of Antiplatelet Therapy After Non-Hemorrhagic Stroke

For patients who have experienced a non-hemorrhagic stroke and are currently on dual antiplatelet therapy (DAPT), clopidogrel should be continued as the long-term single antiplatelet agent while aspirin should be discontinued after the short-term DAPT period.

Duration of Dual Antiplatelet Therapy

According to current guidelines, DAPT should be used for a short, defined period following a non-hemorrhagic stroke:

• For minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4): DAPT with aspirin 81mg daily and clopidogrel 75mg daily should be administered for 21 days 1
• For mild-moderate ischemic stroke (NIHSS ≤5) or high-risk TIA (ABCD2 ≥4): DAPT with aspirin 75-100mg daily and ticagrelor 90mg twice daily should be administered for 30 days 1

Evidence for Short-Term DAPT

Short-term DAPT has demonstrated significant benefits in reducing stroke recurrence:

• Short-term DAPT reduces the risk of recurrent stroke by 26% compared to aspirin alone 2
• Short-term DAPT reduces ischemic stroke recurrence by 28% 2
• Short-term DAPT reduces major adverse cardiovascular events by 24% 2

However, DAPT is associated with increased bleeding risk:

• DAPT increases the risk of moderate or severe bleeding by 88% compared to aspirin monotherapy 2
• The risk of major bleeding increases significantly with longer durations of DAPT 3

Transitioning to Single Antiplatelet Therapy

After completing the short-term DAPT period (21-30 days), patients should transition to long-term single antiplatelet therapy 1, 4:

1. Preferred agent: Clopidogrel 75mg daily

   • The International Journal of Stroke guidelines specifically state that DAPT "should be followed by long-term single antiplatelet therapy with aspirin 81mg daily or clopidogrel 75mg daily" 1
   • When transitioning from DAPT to single antiplatelet therapy, clopidogrel is generally preferred over aspirin for long-term use 4

2. Rationale for choosing clopidogrel:

   • Clopidogrel has shown superior efficacy in secondary stroke prevention compared to aspirin alone 1, 5
   • In patients with previous stroke, aspirin is typically discontinued at the end of the DAPT course, and clopidogrel is continued long-term 1

Special Considerations

• Bleeding risk assessment: Monitor for both minor (bruising) and major bleeding complications during DAPT and after transition to single therapy 4
• Patient education: Inform patients about the importance of adhering to the single antiplatelet therapy after the DAPT period ends 4
• Monitoring: Regular follow-up is essential to ensure adherence and monitor for any adverse effects

Algorithm for Antiplatelet Management After Non-Hemorrhagic Stroke

1. Initial DAPT period (first 21-30 days):

   • Aspirin 81mg daily + Clopidogrel 75mg daily for 21 days, OR
   • Aspirin 75-100mg daily + Ticagrelor 90mg twice daily for 30 days

2. Transition to single antiplatelet therapy:

   • Discontinue aspirin
   • Continue clopidogrel 75mg daily indefinitely

3. If patient has contraindications to clopidogrel:

   • Alternative options include aspirin 81-325mg daily or aspirin 25mg + extended-release dipyridamole 200mg twice daily 1

This approach balances the short-term benefits of DAPT for reducing early recurrent stroke risk while minimizing the long-term bleeding complications associated with continued dual therapy.