Dual Antiplatelet Therapy for Transient Ischemic Attack (TIA)
For patients with high-risk TIA, dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel should be given for 21-30 days, followed by antiplatelet monotherapy indefinitely. 1
Initial DAPT Regimen for TIA
For high-risk TIA (defined as ABCD2 score ≥4), initiate DAPT with:
DAPT should be started as soon as possible after brain imaging has excluded intracranial hemorrhage, ideally within 24 hours of symptom onset and preferably within 12 hours 1
Duration of DAPT should be limited to 21-30 days only 1
Evidence Supporting Short-Duration DAPT
The CHANCE and POINT trials demonstrated that DAPT significantly reduces the risk of recurrent ischemic stroke compared to aspirin alone (HR 0.70,95% CI 0.61-0.81) 3
The benefit of DAPT appears to be confined to the first 21 days after TIA, with no additional benefit observed from day 22 to day 90 3
Short-term DAPT (≤30 days) provides greater reduction in recurrent strokes compared to monotherapy, with less bleeding risk than longer DAPT regimens 4
While DAPT reduces ischemic stroke risk, it increases major hemorrhage risk (0.9% vs. 0.4% in the POINT trial), requiring careful risk-benefit assessment 1
Long-Term Antiplatelet Therapy After DAPT
After completing the 21-30 day DAPT course, patients should transition to antiplatelet monotherapy indefinitely 1
Options for long-term monotherapy include:
Special Considerations
For patients with cardioembolic TIA (e.g., atrial fibrillation), oral anticoagulation is recommended instead of antiplatelet therapy 1
For patients with TIA and unstable angina or non-Q-wave myocardial infarction, long-term DAPT may be indicated 1
For patients with TIA who are candidates for urgent carotid endarterectomy, consider aspirin monotherapy rather than DAPT to reduce perioperative bleeding risk 1
Consider GI protection for patients at higher risk of GI bleeding during DAPT 1
Alternative DAPT Regimens
Recent evidence suggests ticagrelor plus aspirin may be an alternative to clopidogrel plus aspirin, with similar efficacy in preventing recurrent stroke 5, 6
However, ticagrelor plus aspirin may be associated with worse major bleeding outcomes, including intracranial bleeding 6
Network meta-analyses have not shown statistically significant differences between clopidogrel-aspirin and ticagrelor-aspirin for the primary outcome of recurrent stroke or death 5
Common Pitfalls to Avoid
Extending DAPT beyond 30 days increases bleeding risk without providing additional benefit for stroke prevention 1, 7
Delaying initiation of DAPT beyond 24 hours of symptom onset reduces its effectiveness 1
Failing to transition to monotherapy after the DAPT period increases long-term bleeding risk 1, 3
Using triple antiplatelet therapy (aspirin, clopidogrel, and dipyridamole) is not recommended due to increased bleeding risk without additional benefit 1