Using TWO antiplatelets short-term after a minor stroke or transient ischemic attack

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....

More patients will be discharged on a SHORT course of aspirin plus clopidogrel (Plavix) after a minor ischemic stroke or high-risk Transient Ischemic Attack (TIA). We know aspirin alone is generally used to prevent another stroke. But you'll see growing acceptance of 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 combination benefits a broader population. This is a big deal since recurrent strokes can be disabling.

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

Don't suggest starting the second antiplatelet AFTER discharge. Explain that “earlier is better” and there's not much evidence of benefit if the combo's started more than 24 hours post-stroke. Confirm that one antiplatelet, usually clopidogrel, is stopped 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 advise continuing aspirin 81 mg/day ALONE long-term. But clarify why the patient's taking aspirin plus clopidogrel. For example, a recent coronary stent may need the combo for a longer duration.

References

Wang, Y., Wang, Y., and others. (2013). Clopidogrel withn Aspirin in Acute Minor Stroke or Transient Ischemic Attack. New England Journal of Medicine, 369(1), pp.11–19.
Hao, Q., Tampi, M., O’Donnell, et al. Clopidogrel plus aspirin versus aspirin alone for acute minor ischaemic stroke or high risk transient ischaemic attack: systematic review and meta-analysis. BMJ, p.k5108.
Prasad, K., Siemieniuk, R., et al. Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline. BMJ, [online] p.k5130.
Johnston, S.C., Easton, J.D., Farrant, M., Barsan, W., Conwit, R.A., Elm, J.J., Kim, A.S., Lindblad, A.S. and Palesch, Y.Y. (2018). Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. New England Journal of Medicine, 379(3), pp.215–225.