Limit Dual Antiplatelet Therapy After a Stroke or TIA to Short-Term Use

More patients will be discharged on a SHORT course of aspirin plus clopidogrel after a minor ischemic stroke or high-risk TIA.

We know to generally use aspirin ALONE to prevent another stroke.

But you'll see growing acceptance of short-term DUAL antiplatelet therapy in these patients. It's already an option in guidelines...based on positive outcomes in Chinese patients using it for 3 weeks.

Now there's evidence the combo benefits a broader population. This is a big deal...since recurrent strokes can be disabling.

Using low-dose aspirin plus clopidogrel prevents another stroke within the next 3 months in about one in 50 patients versus aspirin alone.

The combo may cause major bleeding in up to one in 200 patients...but doesn't seem to increase intracranial bleeding.

Expect to see more of your patients getting aspirin 81 mg/day plus clopidogrel 75 mg/day after a minor ischemic stroke or high-risk TIA. Use tools, such as the NIH Stroke Scale or ABCD2 score, to spot these patients.

Don't start the second antiplatelet in your office AFTER discharge. Earlier is better...and there's not much evidence of benefit if the combo's started more than 24 hours poststroke.

And don't anticipate use of dual antiplatelet therapy after a major stroke...especially in patients receiving alteplase, due to bleeding risk.

Stop one antiplatelet, usually clopidogrel, within 21 days...or possibly as soon as 10 days for patients at higher bleeding risk. This seems to be the "sweet spot" to maximize benefit and limit bleeding.

Then continue aspirin 81 mg/day ALONE long-term.

Document WHY the patient's taking aspirin plus clopidogrel. For example, a recent coronary stent may need the combo for a longer duration.

See our chart, Antiplatelets for Recurrent Ischemic Stroke, for pros and cons of the various regimens and the role of other meds.

Key References

  • BMJ 2018;363:k5108
  • BMJ 2018;363:k5130
  • N Engl J Med 2018;379(3):215-25
  • N Engl J Med 2013;369(1):11-9
Prescriber's Letter. Mar 2019, No. 350303

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