Dual Antiplatelet Therapy (DAPT) in Ischemic Stroke Management
For patients with recent minor to moderate non-cardioembolic ischemic stroke or high-risk TIA, dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel should be initiated early (within 12-24 hours of symptom onset) and continued for 21-90 days to reduce the risk of recurrent stroke. 1
Patient Selection for DAPT
- DAPT is indicated for patients with recent minor (NIHSS score ≤3) non-cardioembolic ischemic stroke 1
- DAPT is also indicated for patients with high-risk TIA (ABCD2 score ≥4) 1
- DAPT with ticagrelor plus aspirin for 30 days may be considered for patients with recent (<24 hours) minor to moderate stroke (NIHSS score ≤5) or high-risk TIA (ABCD2 score ≥6) 2
- DAPT should only be initiated after excluding intracranial hemorrhage on neuroimaging 1
DAPT Regimen and Duration
- Initial loading doses: aspirin (160-325 mg) and clopidogrel (300-600 mg) 1
- DAPT should be continued for 21 to 90 days after the initial event 2, 1
- Maximum benefit in stroke reduction may occur within the first 21 days after the event 2
- After the DAPT period, patients should transition to single antiplatelet therapy (SAPT) 2
Important Considerations and Contraindications
- DAPT should not be used continuously for >90 days due to excess risk of hemorrhage 2
- Triple antiplatelet therapy is not recommended due to increased bleeding risk without additional benefit 2
- Initiation of anticoagulant therapy within 24 hours of treatment with intravenous rtPA is not recommended 2
- For patients already taking aspirin at the time of non-cardioembolic ischemic stroke or TIA, the effectiveness of increasing the dose or changing to another antiplatelet medication is not well established 2
Evidence Supporting DAPT in Ischemic Stroke
The recommendation for DAPT in early stroke management is based on strong evidence showing reduction in recurrent stroke risk. The American Heart Association/American Stroke Association guidelines strongly support this approach for selected patients 2, 1.
For patients who don't meet criteria for DAPT, single antiplatelet therapy remains the standard of care. The PRoFESS trial found no difference between aspirin-dipyridamole versus clopidogrel for secondary stroke prevention, while the ESPRIT and ESPS2 trials suggested aspirin-dipyridamole may be slightly more effective than aspirin alone 2.
Special Populations
- For patients with symptomatic intracranial atherosclerotic disease, there are limited recommendations supporting DAPT over SAPT 1
- For patients with aortic arch atheroma, antiplatelet therapy is recommended, but the effectiveness of long-term DAPT compared with aspirin monotherapy is unknown 1
- For patients with moyamoya disease and history of ischemic stroke or TIA, aspirin monotherapy may be reasonable 1
Clinical Pitfalls to Avoid
- Avoid continuous use of DAPT beyond 90 days due to increased bleeding risk 2
- Do not use triple antiplatelet therapy due to increased bleeding risk without additional benefit in stroke reduction 2
- Do not initiate anticoagulation within 24 hours of intravenous rtPA treatment 2
- Ensure proper patient selection based on stroke severity (NIHSS score) and TIA risk (ABCD2 score) to maximize benefit and minimize bleeding risk 1