From the Guidelines
Dual Antiplatelet Therapy (DAPT) is indicated for cerebrovascular accident (CVA) or carotid stenosis, but only in specific situations and for a limited duration.
Indications for DAPT
- For patients with symptomatic carotid stenosis, DAPT with low-dose aspirin and clopidogrel is recommended for at least 3 months 1.
- For patients with high-risk transient ischemic attack (TIA) or minor stroke, DAPT is more effective than single antiplatelet therapy (SAPT) for the reduction of recurrent ischemic stroke when initiated soon after the event and continued for 21 to 90 days 1.
Duration of DAPT
- Beyond 90 days after stroke, DAPT is associated with increased risk of bleeding and no benefit in long-term reduction of recurrent stroke risk 1.
- For patients undergoing surgical revascularization, clopidogrel can be stopped after surgery 1.
- For patients undergoing endovascular revascularization, DAPT with clopidogrel and low-dose aspirin should be continued for 4 weeks after the procedure 1.
Important Considerations
- The risk of bleeding should be considered and weighed against the potential benefits of DAPT when initiated early after onset 1.
- The optimal timing of starting treatment relative to the clinical event and the optimal duration of DAPT to maximize the risk-benefit ratio are still uncertain and require additional research 1.
From the Research
Dual Antiplatelet Therapy (DAPT) for Cerebrovascular Accident (CVA) or Carotid Stenosis
- DAPT is indicated for patients with carotid artery stenosis who have experienced a transient ischemic attack or stroke, as it has been shown to be more effective than single antiplatelet therapy (SAPT) in reducing the risk of recurrent stroke 2, 3.
- The optimal duration of DAPT after carotid artery stenting is uncertain, but studies suggest that short-term DAPT (less than 6 months) may be as effective as long-term DAPT in preventing ischemic stroke and bleeding complications 4.
- DAPT using cilostazol has been shown to be superior to SAPT with clopidogrel or aspirin in preventing recurrent stroke and vascular events in patients with intracranial arterial stenosis after stroke, without increasing the risk of bleeding 5.
- Real-world studies have also demonstrated the effectiveness and safety of DAPT in patients with non-cardioembolic mild-to-moderate ischemic stroke, with benefits seen in terms of return to pre-stroke neurological functioning and early neurological improvement 6.
- The selection and duration of antiplatelet therapy in patients with cardiovascular disease, including those with CVA or carotid stenosis, requires careful consideration of both efficacy and safety outcomes, and may involve the use of combination therapies such as DAPT 2, 3.
Key Considerations
- The risk of bleeding complications with DAPT should be carefully weighed against the potential benefits in preventing ischemic stroke and other vascular events 3, 4.
- Individual patient characteristics, such as bleeding risk and cardiovascular disease history, should be taken into account when selecting and duration of antiplatelet therapy 2, 3.
- Further research and clinical trials are needed to optimize antiplatelet treatment in different patient populations and clinical scenarios, including those with CVA or carotid stenosis 2, 3, 4.