What is the recommended antiplatelet therapy for a patient with an acute Cerebrovascular Accident (CVA), comparing Dual Antiplatelet Therapy (DAPT) with single antiplatelet therapy?

Dual Antiplatelet Therapy for Acute Ischemic Stroke

For patients with minor acute ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 score ≥4) of noncardioembolic origin presenting within 24 hours, dual antiplatelet therapy with aspirin plus clopidogrel for exactly 21-30 days is superior to single antiplatelet therapy, followed by lifelong single antiplatelet therapy. 1

Patient Selection Criteria for DAPT

Eligible patients must meet ALL of the following:

• Minor stroke (NIHSS score 0-3) OR high-risk TIA (ABCD2 score ≥4) 1
• Noncardioembolic mechanism (no atrial fibrillation or other cardioembolic source) 1
• Presentation within 24 hours of symptom onset, ideally within 12 hours 1
• Intracranial hemorrhage excluded on neuroimaging 1
• Not receiving or planned for thrombolysis (if alteplase given, delay antiplatelet therapy 24 hours) 1

DAPT Protocol

Loading Dose (Day 1):

• Clopidogrel 300-600 mg (300 mg minimum based on CHANCE trial, up to 600 mg based on POINT trial) 1
• Aspirin 160-325 mg 1

Maintenance Phase (Days 2-21):

• Clopidogrel 75 mg daily 1
• Aspirin 75-100 mg daily 1

After 21-30 Days:

• Switch to single antiplatelet therapy (aspirin 75-100 mg daily OR clopidogrel 75 mg daily) indefinitely 1

Evidence Supporting Limited Duration

The Canadian Stroke Best Practice guidelines specifically limit DAPT to 21-30 days (not the 90 days studied in POINT trial) because: 1

• For every 1000 patients treated for 90 days: 15 ischemic strokes prevented but 5 major hemorrhages caused 1
• Major hemorrhage risk significantly increased with prolonged therapy (HR 2.32,95% CI 1.10-4.87) 1
• Recurrent stroke risk reduced by 25-32% with short-term DAPT (HR 0.72,95% CI 0.56-0.92) 1

Single Antiplatelet Therapy for All Other Acute Strokes

For patients NOT meeting DAPT criteria (moderate-to-severe stroke, presentation >24 hours, or any contraindication):

• Aspirin 160-325 mg loading dose immediately after excluding intracranial hemorrhage 1
• Continue aspirin 81-325 mg daily indefinitely 1
• Alternative: Clopidogrel 75 mg daily (no loading dose needed for monotherapy) 1

Critical Contraindications and Pitfalls

Do NOT use DAPT if:

• Intracranial hemorrhage not yet excluded on imaging 1
• Received IV alteplase within past 24 hours (wait for 24-hour post-thrombolysis scan) 1
• High-grade carotid stenosis requiring urgent endarterectomy (consider aspirin monotherapy to reduce perioperative bleeding) 1
• History of intracranial hemorrhage or high bleeding risk 1

Common Errors to Avoid:

• Never continue DAPT beyond 30 days in stroke patients—bleeding risk outweighs benefit 1
• Never use DAPT as substitute for thrombolysis in eligible patients 2
• Never use ticagrelor or prasugrel instead of clopidogrel for acute stroke (not validated in this population) 1
• Never delay aspirin beyond 48 hours in non-DAPT candidates 2

Special Populations

For dysphagic patients:

• Aspirin 325 mg rectal suppository daily OR aspirin 80 mg + clopidogrel 75 mg via enteral tube 1

For patients with atrial fibrillation:

• Anticoagulation (DOAC preferred) is required instead of antiplatelet therapy 1
• Stop all antiplatelet therapy when safe (typically 2-14 days post-stroke) 1

GI Protection Consideration

For patients on DAPT with high GI bleeding risk, consider proton pump inhibitor therapy, though extracranial bleeding events in the 21-day CHANCE study were only 0.3% in both DAPT and monotherapy groups 1