Ali Saad, MD
Every few years, a meta-analysis comes along to challenge the practice of the ever-controversial ideal antiplatelet regimen in secondary stroke prevention. This meta-analysis looked at 42,234 patients in 17 trials and echoes the current secondary stroke prevention guidelines from the AHA/ASA. Basically, you should definitely prescribe antiplatelets after a stroke (Class 1, Level A), any of the usual agents will do with no clear superiority of one over the other, and there is no evidence to support long term dual antiplatelet therapy. Cilostazol and dipyridamole + asa as monotherapy did outperform aspirin monotherapy for secondary stroke prevention of any type, but that was only in one trial in each case and the results haven’t been reproduced.
It’s worth noting that the AHA/ASA does provide a recommendation for dual antiplatelet under certain circumstances (Class IIb, Level B): ASA + clopidogrel first 21 days after a minor stroke or TIA based on the CHANCE trial. ASA + clopidogrel first 90 days after a minor stroke or TIA if referable to severe stenosis of a large intracranial artery (SAMPPRIS trial). Because it’s not standard of care, it’s up to the provider’s discretion and level of comfort with the evidence provided by these 2 trials. however, everyone seems to agree that long term dual antiplatelet is not indicated and has an increased risk of bleeding. several trials also looked at cilostazol, which may be an option in patients who have a genetic resistance to or don’t respond clinically to clopidogrel.
The advantage of using a meta-analysis is that it shows long-term dual antiplatelet is not a practice that should be instituted for all comers with lacunar stroke. Limitations of this trial, as with any meta-analysis, include not being able to compare individual agents across all endpoints, not having uniform criteria for defining a lacunar stroke, not knowing the status of the patient’s vessels, or compliance with certain meds (namely dipyridamole due to its notoriety for causing headaches). An important limitation is that “long-term” is not uniformly defined; it could be anywhere from weeks to years, and so this data cannot be used to refute the findings of CHANCE or SAMPPRIS.
How does this paper change my practice? It reinforces that there is no indication for long term antiplatelet use for secondary stroke prevention beyond 3 months and reminds me that cilostazol is an option in my armamentarium of antiplatelet drugs. Stay tuned for the results of the POINT study in 2017.