By Matthew E. Fink, MD

Professor and Chairman, Department of Neurology, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital

Dr. Fink reports he is a retained consultant for Proctor & Gamble and Pfizer.

SOURCE: Ge F, Lin H, Liu Y, et al. Duel antiplatelet therapy after stroke or transient ischemic attack – how long to treat? The duration of aspirin plus clopidogrel in stroke or transient ischemic attack: A systematic review and meta-analysis. Eur J Neurol 2016;23:1051-1057.

The CHANCE study showed that the combination of aspirin and clopidogrel was superior to aspirin alone for reducing the risk of stroke in the first 90 days after a transient ischemic attack (TIA) or minor ischemic stroke (N Engl J Med 2013;369:11-19). In its 2014 guidelines, the American Heart Association recommended initiating the combination of aspirin and clopidogrel within 24 hours for a minor ischemic stroke or TIA and continuing for 90 days. However, the CHANCE trial was performed in China with a discrete ethnic population, and it was not clear if the optimal duration of treatment should be 90 days or longer. In ischemic heart disease, treatment with dual antiplatelet therapy beyond one year is the standard of care in patients who have coronary stents, and this question has been unanswered in patients who suffer a TIA or stroke. Therefore, Ge et al performed a comprehensive literature review and meta-analysis, and identified nine randomized, controlled trials that included 21,923 patients. In review of these trials, short-term dual antiplatelet therapy significantly reduced the risk of ischemic stroke recurrence by 41% and major vascular events by 30%, without an increased risk of intracranial hemorrhage. Prolonged treatment beyond 90 days reduced the risk of ischemic stroke recurrence by 12% and major vascular events by 10%. However, the risk of major bleeding and intracranial hemorrhage increased in those patients treated long term. Therefore, it appears that short-term dual antiplatelet therapy is superior to prolonged treatment. However, this difference in outcome must be confirmed by further well-designed randomized, clinical trials.