Elena Zapata-Arriaza, MD

Pan Y, Elm JJ, Li H, Easton JD, Wang Y, Farrant M, et al. Outcomes Associated With Clopidogrel-Aspirin Use in Minor Stroke or Transient Ischemic Attack: A Pooled Analysis of Clopidogrel in High-Risk Patients With Acute Non-Disabling Cerebrovascular Events (CHANCE) and Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trials. JAMA Neurol. 2019;76:1466-1473.

Double antiplatelet therapy (DAT) with Clopidogrel plus Aspirin for TIA and minor ischemic stroke has been widely supported by several clinical trials, allowing its indication in clinical practice guidelines. However, differences in DAT employment duration between studies may increase bleeding risk by canceling the benefit for ischemic events recurrence.

To clarify the optimal DAT duration after TIA or minor ischemic stroke, the authors from the CHANCE and POINT trials performed a pooled analysis of both randomized clinical trials. Primary efficacy outcome was defined as a major ischemic event (ischemic stroke, myocardial infarction or death from ischemic vascular causes), and primary safety outcome was major hemorrhage.

After pooled data assessment, the authors found that early (within first 24 hours after the ischemic event), short-term treatment with clopidogrel-aspirin reduced the risk of major ischemic events without increase in the risk of major hemorrhage at 90 days in patients with minor ischemic stroke or high-risk TIA. In addition, the main net clinical benefit of DAT occurred within the first 3 weeks after the event.

Despite differences in trial design and DAT duration, the inclusion of patients from different settings and populations, and the consistency of results between the 2 trials, the results obtained suggest their ability to be generalizable to a broad range of patients with minor stroke or TIA. The use of DAT in patients with minor non-cardioembolic stroke/TIA has come to solve the two main concerns in this regard: decrease in the recurrence risk of cerebral ischemic events without increased bleeding complications, as long as the start of treatment is within first 24 hours and not exceeding the first 21 days. We have solid evidence about DAT employment in a profile of patients at high risk of ischemic events, so we have sufficient justification to use such therapy in patients with high-risk TIA or minor stroke.