From the Guidelines
Clopidogrel plays a crucial role in the management of minor ischemic stroke or TIA, particularly when used in combination with aspirin as dual antiplatelet therapy (DAPT).
Key Points
- For patients with recent minor (NIHSS score ≤3) noncardioembolic ischemic stroke or high-risk TIA (ABCD2 score ≥4), DAPT with aspirin and clopidogrel should be initiated early, ideally within 12–24 hours of symptom onset, and continued for 21 to 90 days, followed by single antiplatelet therapy (SAPT) 1.
- The combination of aspirin and clopidogrel is recommended for initial therapy in patients with noncardioembolic ischemic stroke or TIA, as it reduces the risk of recurrent ischemic stroke and other cardiovascular events while minimizing the risk of bleeding 1.
- A single loading dose of aspirin (160–325 mg) and clopidogrel (300 mg) should be used at the beginning of DAPT therapy, and the patient should be switched to SAPT after 21 to 90 days 1.
- The use of DAPT with ticagrelor plus aspirin for 30 days may be considered in patients with recent minor to moderate stroke (NIHSS score ≤5) or high-risk TIA (ABCD2 score ≥6), but it may also increase the risk of serious bleeding events, including intracranial hemorrhage (ICH) 1.
- The selection of an antiplatelet agent should be individualized based on patient risk factor profiles, tolerance, and other clinical characteristics 1.
- Continuous use of DAPT for more than 90 days or the use of triple antiplatelet therapy is associated with an excess risk of hemorrhage 1.
From the Research
Role of Clopidogrel in Minor Ischemic Stroke or TIA Management
- Clopidogrel, in combination with aspirin, is effective for secondary prevention after minor ischemic stroke or transient ischemic attack (TIA) 2, 3, 4, 5.
- Dual antiplatelet therapy with clopidogrel and aspirin reduces the risk of major ischemic events, mainly within the first 21 days after minor ischemic stroke or high-risk TIA 2, 4, 5.
- The benefit of dual antiplatelet therapy appears to be confined to the first 21 days after minor ischemic stroke or high-risk TIA, with no significant difference in outcomes beyond this period 2.
- Clopidogrel-aspirin treatment is associated with a higher risk of major hemorrhages, although the difference is often nonsignificant 2, 3, 5.
Comparison with Other Antiplatelet Therapies
- Ticagrelor and aspirin is another dual antiplatelet therapy regimen that is effective in preventing recurrent strokes after minor ischemic stroke or TIA, with similar efficacy to clopidogrel and aspirin 6.
- There is no statistically significant difference between clopidogrel and aspirin compared with ticagrelor and aspirin in the prevention of recurrent stroke and death 6.
Duration and Timing of Clopidogrel Therapy
- Short-duration dual antiplatelet therapy (≤ 1 month) started during the early acute ischemic phase is associated with less bleeding and greater reduction of recurrent strokes compared with monotherapy 5.
- Long-term dual antiplatelet therapy is associated with increased risks of bleeding, with similar rates of any stroke compared with monotherapy 5.