The efficacy of early administration of dual antiplatelet therapy (DAPT) for secondary
prevention after acute ischemic stroke or transient ischemic attack (TIA) is uncertain.
This systematic review and meta-analysis compares the safety and efficacy of early
administration (<24 hours) of DAPT (using either clopidogrel or ticagrelor with aspirin)
versus single antiplatelet therapy (SAPT; aspirin alone) in acute non-cardioembolic
ischemic stroke or TIA, incorporating data from large randomized controlled trials.
Published trials fulfilling our criteria were identified from an electronic search
of MEDLINE, with key words including: “clopidogrel or ticagrelor”, “aspirin”, “ischemic
stroke”, “transient ischemic attack”, and “randomized controlled trial”. Included
were 3 randomized controlled trials of 21,067 patients assessing early administration
(<24 hours from symptom onset) of DAPT versus SAPT in non-cardioembolic acute ischemic
stroke or TIA. Our efficacy outcomes were ischemic stroke and all-cause mortality.
Our safety outcome was severe bleeding. We performed a meta-analysis to pool results
with a hierarchical Bayesian random-effects model. Dual antiplatelet therapy significantly
reduced the risk of ischemic stroke (hazard ratio [HR], 0.73; 95% credible interval
[CrI]: 0.54, 0.97), while increasing the risk of severe bleeding (HR, 2.48; 95% CrI:
1.07, 5.26). There was a non-significant numerical trend toward increased mortality
with DAPT (HR, 1.29; 95% CrI: 0.73, 2.23). These observations were robust under the
sensitivity analysis. In the present systematic review and meta-analysis of randomized
controlled trials, DAPT reduced the risk of ischemic stroke at the cost of an increase
in severe bleeding. Additional trials examining the ideal timing of DAPT administration
are needed to thoroughly investigate the role, if any, of routine DAPT in patients
with non-cardioembolic ischemic stroke or high-risk TIA.
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Article info
Publication history
Published online: July 02, 2021
Received in revised form:
May 7,
2021
Received:
April 16,
2021
Footnotes
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
