What is the recommended DAPT regimen post ischemic CVA for a patient who received thrombolytic medication and was discharged with clopidogrel and aspirin (acetylsalicylic acid)?

From the Guidelines

For a patient who received thrombolytic medication for an ischemic CVA and was discharged with clopidogrel and aspirin, the recommended DAPT regimen is to continue both medications for 21 to 90 days, followed by single antiplatelet therapy (SAPT) with aspirin indefinitely, unless contraindicated, as this approach minimizes the risk of recurrent ischemic stroke and bleeding complications 1. The American Heart Association/American Stroke Association guidelines recommend that patients with noncardioembolic ischemic stroke or TIA should receive antiplatelet therapy, preferably over oral anticoagulation, to reduce the risk of recurrent ischemic stroke and other cardiovascular events while minimizing bleeding risks 1. Key considerations for DAPT regimens include:

• The combination of aspirin and clopidogrel is indicated for secondary prevention of ischemic stroke in patients with noncardioembolic ischemic stroke or TIA 1.
• DAPT should be initiated early, ideally within 12-24 hours of symptom onset, and continued for 21 to 90 days, followed by SAPT 1.
• The use of DAPT for more than 90 days or the use of triple antiplatelet therapy is associated with an excess risk of hemorrhage 1. Monitoring for signs of bleeding complications and regular follow-up appointments are crucial during the transition from DAPT to SAPT. Aspirin and clopidogrel work by inhibiting platelet aggregation through different mechanisms, providing complementary antiplatelet effects that are beneficial in the acute phase following an ischemic stroke 1.

From the Research

DAPT Regimen Post Ischemic CVA

The recommended DAPT regimen post ischemic CVA for a patient who received thrombolytic medication and was discharged with clopidogrel and aspirin (acetylsalicylic acid) is as follows:

• Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel appears to be effective only for patients with minor stroke or TIA when started within 24 hours of the ischemic event and continued for a maximum of 21 days 2
• Short-duration DAPT (≤ 1 month) started during the early acute ischemic phase was associated with less bleeding than longer DAPT and greater reduction of recurrent strokes compared with monotherapy 3
• DAPT involving aspirin plus clopidogrel reduces stroke recurrence and major adverse cardiovascular events but can lead to an increased risk of moderate or severe bleeding compared to aspirin monotherapy 4

Key Considerations

• The benefit of dual antiplatelet therapy appeared to be confined to the first 21 days after minor ischemic stroke or high-risk TIA 5
• Combination antiplatelet therapy with clopidogrel and aspirin may reduce the rate of recurrent stroke during the first 3 months after a minor ischemic stroke or transient ischemic attack (TIA) 6
• The dose of aspirin in each group was selected by the site investigator, with a range of 50 to 325 mg per day 6

Risks and Benefits

• DAPT was associated with significantly lower rates of any stroke and ischemic stroke during any follow-up period, but also with significant increases in intracranial bleeding and major bleeding 3
• The number needed to harm was 258 and 113, respectively, for intracranial bleeding and major bleeding 3
• Major hemorrhages were more frequent in the clopidogrel-aspirin group, but the difference was nonsignificant 5