WHAT IS THE ROLE OF DUAL ANTIPLATELET THERAPY AFTER HIGH RISK TRANSIENT ISCHAEMIC ATTACK OR MINOR STROKE? SPECIFICALLY, DOES DUAL ANTIPLATELET THERAPY WITH A COMBINATION OF ASPIRIN AND CLOPIDOGREL LEAD TO A GREATER REDUCTION IN RECURRENT STROKE AND DEATH OVER THE USE OF ASPIRIN ALONE WHEN GIVEN IN THE FIRST 24 HOURS AFTER A HIGH RISK TRANSIENT ISCHAEMIC ATTACK OR MINOR ISCHAEMIC STROKE? AN EXPERT PANEL PRODUCED A STRONG RECOMMENDATION FOR INITIATING DUAL ANTIPLATELET THERAPY WITHIN 24 HOURS OF THE ONSET OF SYMPTOMS, AND FOR CONTINUING IT FOR 10-21 DAYS CURRENT PRACTICE IS TYPICALLY TO USE A SINGLE DRUG.
This article, although not from a formal specialty society, does a nice job of integrating the current evidence for DAPT after TIA/minor stroke. The recommendation of initiating DAPT within 24 hrs of onset is a change from current practice in this select population. Although this does not have to be started immediately in the ED, this does require some coordination with inpatient management as antiplatelets are often initiated from the ED.
Informative update of TIA dual antiplatelet management rationale. These recommendations should be juxtaposed against ACEP TIA Clinical Policy https://www.sciencedirect.com/science/article/pii/S0196064416303687?via%3Dihub that provides no guidance on antiplatelet options (which the policy should), but does provide a Level B recommendation against use of the ABCD2 score as an accurate predictor of short-term post-TIA stroke risk.
Two papers (see also PMID 30563885) of a BMJ rapid recommendation for dual antiplatelet therapy (clopidogrel + aspirin) result in a small absolute decrease of second CVA after a TIA/small stroke than aspirin alone, with a very small increase in extra-cranial bleeding. A pity this wasn`t generated into a patient decision aid at the same time.
Well presented and easy to understand information that can facilitate change in managing TIA.
With about a 100-fold difference in favor of NNT over NNH (major bleed) and no difference in overall mortality, this is a no-brainer Guideline recommendation and represents the new standard of care.
While this article does not represent new data, it is a clear and concise summary of the available evidence and is likely to be very helpful for internists and other non-specialists who see patients with stroke in their clinical practice.
A concise but fact-filled summary of the data in this area and the need for DAPT after TIA/minor stroke.
As a general internist, I believe this guideline answers the question of how to use DAPT in after TIA and stroke.
This article provides more definitive guidance to recommendations that are already in the literature. Although it is not new, it is very valuable.
This is a very nice concise review of 3 RCTs on dual antiplatelet therapy in high-risk TIA or minor stroke. As a hospitalist, this is an important subset of patients that we frequently see. I did not know that these trials used a loading dose of clopidogrel. I will now add that to my practice. I was not aware of the comparison data between 21 and 90 days, and this article strongly suggests that the best benefit is within the first 10 days, and 21 days is probably enough. I will adjust my practice accordingly.
This and the other associated paper are based on 2 (FASTER was too small) large randomized trials. A meta-analysis is not needed, or maybe not necessarily appropriate as the 2 large trials had different patient populations.
This article simply puts in print what is already in practice.
This clinical practice guideline uses a recent systematic review and meta-analysis of 3 studies and the GRADE process to make recommendations for the use of dual anti-platelet therapy after TIA or minor stroke. The format is very useful for clinicians, definitions are clear, and the rationale for recommendations are transparently provided.