From the Guidelines
Dual antiplatelet therapy (DAPT) after ischemic stroke is typically recommended for 21-90 days, depending on individual patient factors and stroke etiology. The standard regimen consists of aspirin (81-325 mg daily) plus clopidogrel (75 mg daily), with the combination started within 24 hours of symptom onset when possible 1. For minor strokes or high-risk TIAs, 21 days of DAPT is often sufficient, while patients with intracranial atherosclerosis or other high-risk features may benefit from longer durations up to 90 days.
Key Considerations
- The risk of bleeding should be considered and weighed against the potential benefits of DAPT when initiated early after onset 2.
- After the DAPT period, patients should transition to single antiplatelet therapy (typically aspirin or clopidogrel alone) for long-term secondary prevention.
- Patients with atrial fibrillation, mechanical heart valves, or other specific conditions may require different antithrombotic regimens.
- Regular monitoring for bleeding complications is essential during DAPT, and therapy may need adjustment based on individual bleeding risk factors.
Recent Guidelines
- The 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack recommends DAPT for 21 to 90 days in patients with noncardioembolic ischemic stroke or TIA 1.
- A 2023 systematic review and synthesis of global stroke guidelines also supports the use of DAPT for 21 to 90 days in patients with minor ischemic stroke or high-risk TIA 3.
Duration of DAPT
- The optimal duration of DAPT is 21-90 days, with 21 days being sufficient for minor strokes or high-risk TIAs, and longer durations up to 90 days for patients with intracranial atherosclerosis or other high-risk features 1, 3.
- Continuing DAPT for more than 90 days is associated with an excess risk of hemorrhage 1.
From the Research
Dual Antiplatelet Therapy Duration
The recommended duration of dual antiplatelet therapy (DAPT) after an ischemic stroke is a topic of ongoing research and debate.
- Studies have shown that DAPT with aspirin and clopidogrel can reduce the risk of early new stroke in patients with acute mild ischemic stroke or transient ischemic attack (TIA) when initiated within 24 hours of symptom onset 4, 5.
- The optimal duration of DAPT is still uncertain, but research suggests that short-term DAPT (up to 3 months) may be beneficial in preventing recurrent stroke, especially in patients with high-risk transient ischemic attack or mild-moderate ischemic stroke 6, 5.
- However, DAPT is associated with an increased risk of major bleeding, particularly when the treatment is extended for more than 30 days 6, 5.
- Current guidelines do not recommend the routine use of long-term DAPT for secondary stroke prevention, and the decision to use DAPT should be individualized based on the patient's stroke characteristics, time from symptom onset, and predisposition to develop hemorrhagic complications 7, 8.
Key Findings
- A meta-analysis of randomized controlled trials found that 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 5.
- The CHANCE trial found that DAPT with aspirin and clopidogrel started within 24 hours of minor stroke or TIA and continued for 21 days reduced the risk of recurrent stroke 7.
- The SPS3 study found that DAPT was associated with increased bleeding compared to single antiplatelet therapy without an appreciable reduction in ischemic events 7.
Considerations
- The decision to use DAPT should be based on a careful assessment of the patient's individual risk factors and benefits 6, 8.
- Patients with minor stroke or TIA may benefit from short-term DAPT, but the bleeding risk remains uncertain 8.
- Further research is needed to determine the optimal duration and regimen of DAPT for secondary stroke prevention 4, 6, 5, 7, 8.