Dual Antiplatelet Therapy for Large Artery Atherosclerosis
Victor J. Del Brutto, MD
Kim D, Park JM, Kang K, Cho YJ, Hong KS, Lee KB, et al. Dual Versus Mono Antiplatelet Therapy in Large Atherosclerotic Stroke: A Retrospective Analysis of the Nationwide Multicenter Stroke Registry. Stroke. 2019;50:1184–1192.
Large artery atherosclerosis (LAA) is responsible for a fourth of all ischemic strokes and is the mechanism of cerebral ischemia with the highest risk of recurrence. Current evidence supports that aggressive platelet anti-aggregation is beneficial in the acute phase due to the high thrombogenicity caused by plaque rupture, while the use of statins and strict vascular risk factors control is more relevant chronically to assure plaque stability and to stop arterial disease progression. Current guidelines recommend long-term antiplatelet monotherapy for secondary stroke prevention. However, high-risk clinical settings such as coexistence of coronary artery disease, stroke recurrence despite taking one antiplatelet agent, high-degree stenosis, or presence of micorembolic signals on transcranial Doppler often lead physicians to prescribe dual antiplatelet therapy (DAPT) beyond the acute phase.
The current study used a large multicenter prospective stroke registry from Korea to compare the effectiveness of DAPT with clopidogrel plus aspirin versus aspirin monotherapy in preventing vascular events and death in patients who had an ischemic stroke or TIA attributed to LAA. At one-year follow up, combination therapy was associated with lower risk of having the composite outcome of any stroke, myocardial infarction, or all-cause death. Of notice, DAPT did not reduce the risk of stroke recurrence when compared to aspirin alone, thus results were mainly attributable to overall mortality reduction (Figure 4).