Andy Lim, MBA, FACEM, GAICD
Another landmark has been reached to inform the early management of transient ischemic attack (TIA) and minor stroke. If you have not heard already, the THALES (Acute STroke or Transient IscHaemic Attack Treated With TicAgreLor and ASA for PrEvention of Stroke and Death) trial has recently hit the stroke scene. THALES was an international randomized controlled trial that found that early dual antiplatelet therapy (DAPT) for TIA and minor stroke (aspirin + ticagrelor) was superior to aspirin alone in the prevention of recurrent stroke or death.
Xiong and Bath pave the way forward in their recent review article in this field. The authors have pointed out three important points that have not remained answered, and therefore, directions for future research. First, exclusion of patients eligible for reperfusion therapy makes these findings less generalizable to this subgroup. Second, the optimal duration of aspirin + ticagrelor has not yet been established, and more information is required regarding bleeding rates as a function of time. Third, using aspirin as a control arm may no longer be the most relevant comparator, and aspirin + ticagrelor and aspirin + clopidogrel are yet to be compared.
So, this is the current state of thinking — the evidence tells us that dual antiplatelet therapy is beneficial in the early management of transient ischaemic attack and minor stroke, but the role of each combination is not yet elucidated.
Keep an eye out for the CHANCE-2 (Clopidogrel With Aspirin in High-risk Patients With Acute Non-disabling Cerebrovascular Events II) trial — this will shed some light on how aspirin + ticagrelor fits into treatment decisions by comparing aspirin + clopidogrel versus aspirin + ticagrelor in patients with clopidogrel resistance. For now, whether we should change to aspirin + ticagrelor or use it as a backup choice is yet to be resolved.