Comparison of Ticagrelor vs Clopidogrel in Addition to Aspirin in Patients With Minor Ischemic Stroke and Transient Ischemic Attack

Background: Evidence about the use of dual antiplatelet therapy (DAPT) with aspirin and P2Y12 inhibitors in patients with acute minor ischemic stroke or transient ischemic attack (TIA) is emerging. The aim of our study was to provide an updated and comprehensive analysis about the risks and benefits of DAPT versus aspirin monotherapy in this setting. Methods: The PubMed, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov databases, main international conference proceedings were searched for randomized controlled trials comparing DAPT versus aspirin monotherapy in patients with acute ischemic stroke or TIA not eligible for thrombolysis or thrombectomy presenting in the first 24 hours after the acute event. Data were pooled by meta-analysis using a random-effects model. The primary efficacy endpoint was ischemic stroke recurrence, and the primary safety outcome was major bleeding. Secondary endpoints were intracranial hemorrhage, hemorrhagic stroke, and all-cause death. Results: A total of 4 studies enrolling 21,459 patients were included. DAPT with clopidogrel was used in 3 studies, DAPT with ticagrelor in one study. DAPT duration was 21 days in one study, 1 month in one study, and 3 months in the remaining studies. DAPT was associated with a significant reduction in the risk of ischemic stroke recurrence (relative risk [RR], 0.74; 95% confidence interval [CI], 0.67-0.82, P<0.001, number needed to treat 50 [95% CI 40-72], while it was associated with a significantly higher risk of major bleeding (RR, 2.59; 95% CI 1.49-4.53, P=0.001, number needed to harm 330 [95% CI 149-1111]), of intracranial hemorrhage (RR 3.06, 95% CI 1.41-6.66, P=0.005), with a trend towards higher risk of hemorrhagic stroke (RR 1.83, 95% CI 0.83-4.05, P=0.14), and a slight tendency towards higher risk of all-cause death (RR 1.30, 95% CI 0.89-1.89, P=0.16). Conclusions: Among patients with acute minor ischemic stroke or TIA, DAPT, as compared with aspirin monotherapy, might offer better effectiveness in terms of ischemic stroke recurrence at the expense of a higher risk of major bleeding. The trade-off between ischemic benefits and bleeding risks should be assessed in tailoring the therapeutic strategies.

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Corneal nerve and endothelial cell damage in patients with transient ischemic attack and minor ischemic stroke

PLoS ONE ◽

10.1371/journal.pone.0213319 ◽

2019 ◽

Vol 14 (3) ◽

pp. e0213319 ◽

Cited By ~ 4

Author(s):

Hoda Gad ◽

Adnan Khan ◽

Naveed Akhtar ◽

Saadat Kamran ◽

Ahmed El-Sotouhy ◽

...

Keyword(s):

Ischemic Stroke ◽

Endothelial Cell ◽

Transient Ischemic Attack ◽

Cell Damage ◽

Endothelial Cell Damage ◽

Minor Ischemic Stroke ◽

Corneal Nerve ◽

Ischemic Attack

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PCV90 RISK FACTORS, USE OF HEALTH CARE RESOURCES, AND MORTALITY IN PATIENTS WITH MINOR ISCHEMIC STROKE OR HIGH-RISK TRANSIENT ISCHEMIC ATTACK

Value in Health ◽

10.1016/j.jval.2019.09.814 ◽

2019 ◽

Vol 22 ◽

pp. S558

Author(s):

O. Fasth ◽

P. Appelros ◽

B. Farahmand ◽

J. Hedberg ◽

P. Ladenvall ◽

...

Keyword(s):

Risk Factors ◽

Health Care ◽

Ischemic Stroke ◽

High Risk ◽

Transient Ischemic Attack ◽

Health Care Resources ◽

Minor Ischemic Stroke ◽

Ischemic Attack ◽

Use Of Health Care

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Diagnostic Usefulness of the ABCD 2 Score to Distinguish Transient Ischemic Attack and Minor Ischemic Stroke From Noncerebrovascular Events

Stroke ◽

10.1161/strokeaha.109.557074 ◽

2009 ◽

Vol 40 (11) ◽

pp. 3449-3454 ◽

Cited By ~ 61

Author(s):

Orla C. Sheehan ◽

Aine Merwick ◽

Lisa A. Kelly ◽

Niamh Hannon ◽

Michael Marnane ◽

...

Keyword(s):

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Minor Ischemic Stroke ◽

Diagnostic Usefulness ◽

Ischemic Attack

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Risk factors for cervical atherosclerosis in patients with transient ischemic attack or minor ischemic stroke.

Stroke ◽

10.1161/01.str.24.7.970 ◽

1993 ◽

Vol 24 (7) ◽

pp. 970-975 ◽

Cited By ~ 25

Author(s):

H Palomäki ◽

M Kaste ◽

R Raininko ◽

O Salonen ◽

S Juvela ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Minor Ischemic Stroke ◽

Ischemic Attack

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Antiplatelet therapy in stroke prevention after non-cardioembolic transient ischemic attack

Neurology neuropsychiatry Psychosomatics ◽

10.14412/2074-2711-2021-5-14-19 ◽

2021 ◽

Vol 13 (5) ◽

pp. 14-19

Author(s):

A. V. Fonyakin ◽

L. A. Geraskina ◽

M. Yu. Maksimova

Keyword(s):

Ischemic Stroke ◽

Antiplatelet Therapy ◽

Transient Ischemic Attack ◽

Antiplatelet Agents ◽

Basic Principles ◽

Advantages And Disadvantages ◽

Minor Ischemic Stroke ◽

New Ideas ◽

Ischemic Attack

The review shows modern concepts on the role of antiplatelet therapy in the secondary prevention of cardiovascular diseases in patients after non-cardioembolic ischemic stroke or transient ischemic attack (TIA). We present an analytical characteristic of all antiplatelet agents that have been studied in randomized controlled trials worldwide. We demonstrate the advantages and disadvantages of each agent in monotherapy and in combination. New ideas about the rationality of the use of combined antiplatelet therapy with clopidogrel and acetylsalicylic acid in the first 24 hours and no more than 90 days in patients with minor ischemic stroke or TIA are discussed. The efficacy and safety of new antiplatelet agents are analyzed. The basic principles of choosing antiplatelet agents in patients after ischemic noncardioembolic stroke/TIA are outlined.

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Correction: Corneal nerve and endothelial cell damage in patients with transient ischemic attack and minor ischemic stroke

PLoS ONE ◽

10.1371/journal.pone.0217672 ◽

2019 ◽

Vol 14 (5) ◽

pp. e0217672

Author(s):

Hoda Gad ◽

Adnan Khan ◽

Naveed Akhtar ◽

Saadat Kamran ◽

Ahmed El-Sotouhy ◽

...

Keyword(s):

Ischemic Stroke ◽

Endothelial Cell ◽

Transient Ischemic Attack ◽

Cell Damage ◽

Endothelial Cell Damage ◽

Minor Ischemic Stroke ◽

Corneal Nerve ◽

Ischemic Attack

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Time Course for Benefit and Risk of Clopidogrel and Aspirin After Acute Transient Ischemic Attack and Minor Ischemic Stroke

Circulation ◽

10.1161/circulationaha.119.040713 ◽

2019 ◽

Vol 140 (8) ◽

pp. 658-664 ◽

Cited By ~ 11

Author(s):

S. Claiborne Johnston ◽

Jordan J. Elm ◽

J. Donald Easton ◽

Mary Farrant ◽

William G. Barsan ◽

...

Keyword(s):

Ischemic Stroke ◽

High Risk ◽

Transient Ischemic Attack ◽

Time Course ◽

Hazard Ratio ◽

Major Hemorrhage ◽

Minor Ischemic Stroke ◽

Ischemic Attack ◽

Ischemic Events ◽

Benefit And Risk

Background: In patients with acute minor ischemic stroke or high-risk transient ischemic attack enrolled in the POINT trial (Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke [POINT] Trial), the combination of clopidogrel and aspirin for 90 days reduced major ischemic events but increased major hemorrhage in comparison to aspirin alone. Methods: In a secondary analysis of POINT (N=4881), we assessed the time course for benefit and risk from the combination of clopidogrel and aspirin. The primary efficacy outcome was a composite of ischemic stroke, myocardial infarction, or ischemic vascular death. The primary safety outcome was major hemorrhage. Risks and benefits were estimated for delayed times of treatment initiation using left-truncated models. Results: Through 90 days, the rate of major ischemic events was initially high then decreased markedly, whereas the rate of major hemorrhage remained low but relatively constant throughout. With the use of a model-based approach, the optimal change point for major ischemic events was 21 days (0–21 days hazard ratio 0.65 for clopidogrel-aspirin versus aspirin; 95% CI, 0.50–0.85; P =0.0015, in comparison to 22–90 days hazard ratio, 1.38; 95% CI, 0.81–2.35; P =0.24). Models showed benefits of clopidogrel-aspirin for treatment delayed as long as 3 days after symptom onset. Conclusions: The benefit of clopidogrel-aspirin occurs predominantly within the first 21 days, and outweighs the low, but ongoing risk of major hemorrhage. When considered with the results of the CHANCE trial (Clopidogrel in High-Risk Patients With Non-disabling Cerebrovascular Events), a similar trial treating with clopidogrel-aspirin for 21 days and showing no increase in major hemorrhage, these results suggest that limiting clopidogrel-aspirin use to 21 days may maximize benefit and reduce risk after high-risk transient ischemic attack or minor ischemic stroke. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00991029.

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