DAPT after an ischemic stroke or TIA?

Now a new study examines starting DAPT within 72 hours and includes patients with slightly worse symptoms, an NIHSS score of 5 or less...
Abdelwahab Ward, BS Pharm, PharmD

Overview

New data will raise questions about optimal use of short-term dual antiplatelet therapy (DAPT) after an ischemic stroke or TIA. We know that short-term DAPT, such as aspirin plus clopidogrel for 21 days, reduces recurrent stroke risk compared to aspirin alone. But most evidence is with starting DAPT within 24 hours. And data are mostly for patients with a minor stroke, an NIH Stroke Scale (NIHSS) score of 3 or less out of 42 points or high-risk TIA, an ABCD2 score of 4 or more out 7 points.

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Management

Expanding DAPT timing and criteria

Now a new study examines starting DAPT within 72 hours and includes patients with slightly worse symptoms, an NIHSS score of 5 or less. In these cases, aspirin plus clopidogrel for 21 days prevents 1 recurrent stroke for every 53 patients treated compared to aspirin alone. And it leads to moderate to severe bleeding for 1 in 200 patients. Think of these outcomes as roughly similar to other studies of short-term aspirin plus clopidogrel after a minor stroke or TIA.

Guiding DAPT use for stroke prevention

Guide use of DAPT to reduce recurrent stroke risk in select cases. For example, start a short course of DAPT for patients with a high-risk TIA or milder stroke, NIHSS score of 5 or less. But avoid DAPT with more severe strokes or for patients who got a thrombolytic or take an anticoagulant. There’s no proof that benefit outweighs risk in these cases.

  • Continue to start DAPT ASAP, since recurrent stroke risk is highest during the first couple days poststroke. But think of these newer data as support for starting up to 72 hours poststroke if necessary, such as due to delays in seeking care.
    • Generally, choose aspirin plus clopidogrel.
      • Consider a loading dose of clopidogrel (Plavix) 300 mg plus up to 325 mg of aspirin, then step down to clopidogrel 75 mg/day plus aspirin 81 mg/day.
    • Be aware, ticagrelor (Brilique) plus aspirin also decreases recurrent stroke risk. But this combo seems to increase risk of intracranial hemorrhage. Plus, ticagrelor must be taken BID, can cause dyspnea, and is significantly more expensive compared to clopidogrel

Recommended duration for DAPT

Ensure that DAPT is stopped after 21 days, or possibly after 10 days for patients at higher bleeding risk. This seems to be the “sweet spot” to maximize benefit and limit bleeding. Provide clear discharge instructions about when patients will transition to ONE long-term antiplatelet, generally aspirin 81 mg/day. For more data, read our note "Antiplatelets options for recurrent ischemic stroke".

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References

  1. Gao Y, Chen W, Pan Y, et al. Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke. N Engl J Med. 2023;389(26):2413-2424.
  2. Kim AS. Extending Dual Antiplatelet Therapy for TIA or Stroke. N Engl J Med. 2023;389(26):2478-2479.
  3. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364-e467.
Abdelwahab Ward, BS Pharm, PharmD