Antiplatelet therapy in stroke prevention after non-cardioembolic transient 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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In people with a transient ischemic attack or a minor ischemic stroke of presumed arterial origin, how do vitamin K antagonists compare with antiplatelet therapy at improving outcomes?

Cochrane Clinical Answers ◽

10.1002/cca.207 ◽

2013 ◽

Author(s):

Terry J. Quinn

Keyword(s):

Ischemic Stroke ◽

Antiplatelet Therapy ◽

Vitamin K ◽

Transient Ischemic Attack ◽

Vitamin K Antagonists ◽

Minor Ischemic Stroke ◽

Ischemic Attack ◽

A Minor

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Dual Antiplatelet Therapy Versus Aspirin in Patients With Stroke or Transient Ischemic Attack

Stroke ◽

10.1161/strokeaha.120.033033 ◽

2021 ◽

Author(s):

Kirtipal Bhatia ◽

Vardhmaan Jain ◽

Devika Aggarwal ◽

Muthiah Vaduganathan ◽

Sameer Arora ◽

...

Keyword(s):

Ischemic Stroke ◽

Antiplatelet Therapy ◽

Major Bleeding ◽

Transient Ischemic Attack ◽

Dual Antiplatelet Therapy ◽

Recurrent Stroke ◽

Major Adverse Cardiovascular Events ◽

Short Term ◽

Ischemic Attack

Background and Purpose: Antiplatelet therapy is key for preventing thrombotic events after transient ischemic attack or ischemic stroke. Although the role of aspirin is well established, there is emerging evidence for the role of short-term dual antiplatelet therapy (DAPT) in preventing recurrent stroke. Methods: We conducted a systematic review and study-level meta-analyses of randomized controlled trials comparing outcomes of early initiation of short-term DAPT (aspirin+P2Y12 inhibitor for up to 3 months) versus aspirin alone in patients with acute stroke or transient ischemic attack. Primary efficacy outcome was risk of recurrent stroke and primary safety outcome was incidence of major bleeding. Secondary outcomes studied were risk of any ischemic stroke, hemorrhagic stroke, major adverse cardiovascular events, and all-cause death. Pooled risk ratios (RRs) and CIs were calculated using a random-effects model. Results: Four trials with a total of 21 459 patients were included. As compared to aspirin alone, DAPT had a lower risk of recurrent stroke (RR, 0.76 [95% CI, 0.68–0.83]; P <0.001; I 2 = 0%) but a higher risk of major bleeding events (RR, 2.22 [95% CI, 1.14–4.34], P =0.02, I 2 = 46.5%). Patients receiving DAPT had a lower risk of major adverse cardiovascular events (RR, 0.76 [95% CI, 0.69–0.84], P <0.001, I 2 = 0%) and recurrent ischemic events (RR, 0.74 [95% CI, 0.67–0.82], P <0.001, I 2 = 0%). Conclusions: As compared to aspirin alone, short-term DAPT within 24 hours of high-risk transient ischemic attack or mild-moderate ischemic stroke reduces the risk of recurrent stroke at the expense of higher risk of major bleeding.

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Personalized antiplatelet therapy based on clopidogrel/aspirin resistance tests in acute ischemic stroke and transient ischemic attack: Study protocol of a multi-center, single-blinded and randomized controlled trial

Contemporary Clinical Trials ◽

10.1016/j.cct.2021.106507 ◽

2021 ◽

pp. 106507

Author(s):

Mengqi Han ◽

Jiajing Wang ◽

Jie Kuang ◽

Jianglong Tu ◽

Katherine Starcevich ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Antiplatelet Therapy ◽

Transient Ischemic Attack ◽

Controlled Trial ◽

Aspirin Resistance ◽

Randomized Controlled ◽

Ischemic Attack ◽

Resistance Tests

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Response to Letter Regarding Article, “Early Dual Versus Mono Antiplatelet Therapy for Acute Non-Cardioembolic Ischemic Stroke or Transient Ischemic Attack: An Updated Systematic Review and Meta-Analysis”

Circulation ◽

10.1161/circulationaha.114.009357 ◽

2014 ◽

Vol 130 (8) ◽

Author(s):

Ka Sing Lawrence Wong ◽

Yilong Wang ◽

Xinyi Leng ◽

Chen Mao ◽

Jinling Tang ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Antiplatelet Therapy ◽

Transient Ischemic Attack ◽

Meta Analysis ◽

Dual Versus ◽

Ischemic Attack

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Hemostatic Activity in Patients with a Transient Ischemic Attack or Minor Ischemic Stroke with or without Chronic Non-Valvular Atrial Fibrillation

Cerebrovascular Diseases ◽

10.1159/000108730 ◽

1993 ◽

Vol 3 (6) ◽

pp. 350-356

Author(s):

Gheorghe A. Pop ◽

Han J. Meeder ◽

Wynsen van Oudenaarden ◽

Jeannette C. van Latum ◽

Wim Verweij ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Transient Ischemic Attack ◽

Minor Ischemic Stroke ◽

Hemostatic Activity ◽

Ischemic Attack

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Clinical Effects of Dual Antiplatelet Therapy or Aspirin Monotherapy after Acute Minor Ischemic Stroke or Transient Ischemic Attack, a Meta-Analysis

Current Pharmaceutical Design ◽

10.2174/1381612827666210728102459 ◽

2021 ◽

Vol 27 ◽

Author(s):

Francesco Condello ◽

Gaetano Liccardo ◽

Giuseppe Ferrante

Keyword(s):

Ischemic Stroke ◽

Major Bleeding ◽

Transient Ischemic Attack ◽

Hemorrhagic Stroke ◽

Dual Antiplatelet Therapy ◽

Meta Analysis ◽

Stroke Recurrence ◽

Controlled Trials ◽

Minor Ischemic Stroke ◽

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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