Wern Yew Ding, MBChB

Bhatia K, Jain V, Aggarwal D, Vaduganathan M, Arora S, Hussain Z, Uberoi G, Tafur A, Zhang C, Ricciardi M, Qamar A. Dual Antiplatelet Therapy Versus Aspirin in Patients With Stroke or Transient Ischemic Attack: Meta-Analysis of Randomized Controlled Trials. Stroke. 2021;52:e217–e223.

Transient ischemic attack (TIA)/cerebral vascular accident (CVA) and acute coronary syndrome share many similarities. An integral element to the management of patients with either condition includes the use of antiplatelet therapy to reduce the risk of recurrent events. In acute coronary syndrome, the administration of dual antiplatelet therapy (DAPT) has been established, while this is less certain in TIA/CVA. Recently, several trials have investigated this issue. In this meta-analysis by Bhatia and colleagues, they sought to compare the safety and efficacy of aspirin plus a P2Y12 inhibitor against aspirin alone for the prevention of recurrent stroke in patients with minor ischemic stroke or high-risk TIA.

The authors performed a thorough literature search to identify a total of 8,211 citations, of which, 4 were eventually included in this article with a total of 21,459 patients. Patients with presumed cardioembolic stroke, who received thrombolysis, were planned for endovascular therapy and had underlying indications for anticoagulation were excluded. Compared to aspirin alone, DAPT was associated with a lower risk of recurrent stroke (ischemic and hemorrhagic), major adverse cardiovascular event and recurrent ischemic event but with greater risk of major bleeding. There was no difference in the risk of hemorrhagic stroke or all-cause death between DAPT vs. aspirin alone. Overall, the authors surmised that current data supports the use of DAPT in patients with minor ischemic stroke or TIA.

An important limitation of this meta-analysis is the fact that there was significant variability between the included studies in terms of type of antiplatelet agent, dose of antiplatelet agent, duration of antiplatelet therapy and duration of follow-up. Therefore, these are practical issues that remain to be addressed before widespread use of DAPT may be advocated. From a theoretical perspective, it is expected that the use of more potent antiplatelet agents at higher doses and for longer duration would result in a reduced risk of recurrent events but an increased risk of major bleeding — as observed with acute coronary syndrome. Hence, the optimal treatment regime needs to be defined, balancing the benefit of treatment with the risk of potential harm. In this regard, an individualized treatment strategy should be adopted after consideration of the patient’s underlying thrombotic and bleeding risk profile.