Duration of Dual Antiplatelet Therapy (DAPT) in Stroke Patients
For patients with minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4), DAPT with aspirin and clopidogrel should be given for 21 days, followed by long-term single antiplatelet therapy. 1
DAPT Duration Recommendations Based on Stroke Type
Minor Ischemic Stroke or High-Risk TIA
- For patients with minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4), DAPT with aspirin 81 mg daily and clopidogrel 75 mg daily should be initiated as early as possible, ideally within 12-24 hours of symptom onset 1
- A loading dose of aspirin (160-325 mg) and clopidogrel (300-600 mg) should be given at the start of therapy 1
- DAPT should be continued for 21 days, then followed by long-term single antiplatelet therapy with either aspirin or clopidogrel 1
Mild-Moderate Ischemic Stroke with Ticagrelor
- For patients with mild-moderate ischemic stroke (NIHSS ≤5) or high-risk TIA (ABCD2 ≥4), DAPT with aspirin 75-100 mg daily and ticagrelor 90 mg twice daily can be initiated within 24 hours 1
- A loading dose of aspirin (300-325 mg) and ticagrelor (180 mg) should be used at the beginning of therapy 1
- This DAPT combination should be continued for 30 days, then followed by long-term single antiplatelet therapy 1
Intracranial Atherosclerotic Disease
- For patients with moderate to high-grade intracranial atherosclerotic stenosis (50-99%), DAPT is recommended as appropriate medical therapy 1
- Some evidence suggests DAPT may be beneficial for up to 90 days in patients with large vessel intracranial atherosclerotic disease 2
Important Considerations for DAPT Duration
Benefits of Short-Term DAPT
- Short-term DAPT (≤3 months) significantly reduces the risk of ischemic stroke recurrence by 41% and major vascular events by 30% 3
- DAPT initiated early (within 24 hours) after minor stroke or TIA provides greater reduction of recurrent strokes compared to monotherapy 4, 5
- The number needed to treat to prevent one primary outcome event is approximately 92 1
Risks of Prolonged DAPT
- Long-term use of DAPT (>90 days) has been shown to have no benefit over single antiplatelet therapy for recurrent stroke prevention 1
- Prolonged DAPT significantly increases the risk of intracranial hemorrhage and major bleeding 3, 4
- The number needed to harm for severe bleeding is approximately 263 1
- Older patients and those with more severe strokes appear to be at higher risk of intracranial hemorrhage with DAPT 1
Transition to Long-Term Therapy
- After the recommended DAPT duration (21-30 days), patients should transition to long-term single antiplatelet therapy 1
- Options for long-term single antiplatelet therapy include:
Special Considerations
Extracranial Artery Dissection
- In patients with ischemic stroke or TIA and extracranial carotid or vertebral artery dissection, either antiplatelet therapy or oral anticoagulants are recommended for at least 3 months 1
Embolic Stroke of Undetermined Source (ESUS)
- Patients with ESUS should not receive oral anticoagulants; antiplatelet therapy is the recommended antithrombotic regimen 1
Common Pitfalls and Caveats
- Triple antiplatelet therapy has been shown to increase bleeding risk without improving outcomes and should be avoided 1
- There may be non-stroke-related indications for DAPT beyond the recommended duration (e.g., recent drug-eluting cardiac stent placement), but these indications should be clearly documented to ensure DAPT is not continued indefinitely 1
- For patients already taking aspirin at the time of stroke, the effectiveness of increasing the dose or changing to another antiplatelet medication is not well established 1
- Prasugrel should not be administered to patients with a prior history of stroke or TIA due to increased risk of cerebrovascular events 1, 6
The optimal duration of DAPT appears to be 21-30 days for most patients with ischemic stroke or TIA, as this provides the best balance between reducing recurrent stroke risk and minimizing bleeding complications 3, 4, 5.