Highlights
- •This paper corroborates the role of dual antiplatelet therapy (DAPT) both for acute treatment and secondary prevention of non-cardioembolic minor ischemic stroke and high-risk TIA.
- •The early administration (within 24 h from symptoms onset) of a P2Y12 inhibitor plus aspirin showed an absolute risk reduction of stroke recurrence about 2% and an absolute risk increase of major bleeding about 0.4%.
- •There was apparently no correlation between therapy duration and bleeding risk, differently from what previously obtained from other studies, probably due to association of ticagrelor plus aspirin.
- •The early use of DAPT reduces functional disability, compared to aspirin alone.
- •It is possible to hypothesize a personalization of therapy based on the clinical presentation severity and the bleeding risk profile of patients.
Abstract
Background
Aspirin is a cornerstone of preventive treatment for stroke recurrence, but during
the last few years the role of dual antiplatelet therapy (DAPT) is much more emerging.
Objective
This systematic review aimed to compare early use of P2Y12 inhibitors (clopidogrel/ticagrelor)
plus aspirin to aspirin alone for acute treatment and secondary prevention in acute
non-cardioembolic minor ischemic stroke or TIA.
Methods
A systematic search on MEDLINE and EMBASE was performed. Treatment effects were estimated
with RRs and 95% CI. We used RevMan 5.4 for data analyses. We assessed methodological
quality of selected studies according to Rob2 tools and quality of evidence with GRADE
approach.
Results
Four RCTs were included, enrolling 21,459 patients. Compared to aspirin alone, DAPT
was superior in reducing stroke recurrence (RR 0.74, 95% CI 0.67–0.82, P <0.00001, absolute risk difference by 2%, NNT 50) and disabling stroke defined as
mRS>2 (RR 0.84, 95% CI 0.75–0.95, P = 0.004), with no impact on all causes of mortality (RR 1.30, 95% CI 0.90–1.89, P = 0.16). An increased risk of major bleeding was emerged (RR 2.54, 95% CI 1.65–3.92,
P <0.0001, absolute risk difference by 0,4%, NNH 250), in particular with ticagrelor,
but there was no correlation between therapy duration and bleeding risk, as appeared
from one-month (RR 3.06, 95% CI 1.64 to 5.69) and three-month (RR 2.09, 95% CI 1.18
to 3.69) follow-up analysis.
Conclusions
Early administration of P2Y12 inhibitors plus aspirin in patients with acute non-cardioembolic
minor ischemic stroke or TIA reduced the incidence of ischemic stroke recurrence,
impacting more significantly than the increased bleeding risk and influencing patients’
quality of life by reducing disabling stroke.
Keywords
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Article info
Publication history
Published online: March 21, 2022
Accepted:
March 16,
2022
Received in revised form:
March 14,
2022
Received:
November 17,
2021
Identification
Copyright
© 2022 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
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- Dual antiplatelet treatment for minor acute ischemic stroke and high-risk transient ischemic attack: have we reached the limit of antithrombotic management?European Journal of Internal MedicineVol. 100
- PreviewIn this issue of the European Journal of Internal Medicine Pomero et al. present their systematic review and meta-analysis evaluating the early use of clopidogrel and ticagrelor in addition to aspirin for the treatment of patients presenting with an acute non-cardioembolic minor acute ischemic stroke or transient ischemic attack (TIA) [1].
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