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Combination Antiplatelet Therapy for Transient Ischemic Attack or Minor Stroke: Does It Work?

June 26, 2013

Combination Antiplatelet Therapy for Transient Ischemic Attack or Minor Stroke: Does It Work?

  1. Seemant Chaturvedi, MDAU218

Results of a study in China suggest that it might.

  1. Seemant Chaturvedi, MDAU218

To compare the effects of aspirin plus clopidogrel with aspirin alone in minor stroke or transient ischemic attack (TIA), more than 100 centers in China recruited a total of 5170 patients with a diagnosis of “high-risk” TIA or minor stroke within 24 hours of symptom onset. High-risk TIA was defined as a score of ≥4 on the ABCD2 scale, which is based on age, blood pressure, and other clinical variables. Minor stroke was defined as a score of ≤3 on the NIH Stroke Scale score.

All patients received aspirin (75–300 mg) on day 1 and 75 mg of aspirin through day 21. Those randomized to dual antiplatelet therapy received 300 mg of clopidogrel on day 1 and 75 mg on days 2 through 90, with aspirin placebo on days 22 through 90. Those randomized to aspirin alone continued on 75 mg of aspirin daily though day 90, with clopidogrel placebo on days 1 through 90.

During the 90-day follow-up period, there was a significant, 32% relative reduction in the rate of stroke with dual antiplatelet therapy (11.7% with aspirin alone, 8.2% with the combination; hazard ratio, 0.68) and a significant reduction in the combination of fatal or disabling stroke (HR, 0.75). Major extracranial or intracranial hemorrhages did not differ (0.3% in both groups).

Comment

Some treatments initially used for cardiac disease (e.g., thrombolysis and statins) have percolated into the prevention and treatment of stroke. Other treatments commonly used for cardiac disease, such as intravenous heparin, have not been proven useful for stroke.

What about dual antiplatelet therapy, which is effective for acute coronary syndromes? This study showed an impressive 32% relative and 3.5% absolute reduction in the rate of stroke with dual antiplatelet therapy. Asian populations differ from others with respect to the pathophysiology of stroke, such as greater frequency of intracranial stenosis. A North American study with a similar design is in progress (the POINT trial). If the second study confirms the benefits of dual antiplatelet therapy, another “cardiac” treatment could soon be applied to patients with cerebrovascular disease.

Dr. S. Claiborne Johnston was a coauthor of the study reviewed here. He was not involved in the selection of this study for coverage in NEJM Journal Watch, nor was he involved in the editing of this coverage.

  • Disclosures for Seemant Chaturvedi, MD at time of publication Consultant / Advisory board Abbott Vascular; Boeringher-Ingelheim; Genentech; Thornhill Research Grant / research support Pfizer Editorial boards Neurology; Stroke Leadership positions in professional societies American Academy of Neurology (Vice Chair of Vascular Neurology Section)

Citation(s):

Reader Comments (4)

Dr. V Kantariya MD Physician, Family Medicine/General Practice

Dual Antiplatelet therapy in TIA is good for Brain. Minor Ischemic Stroke=Big Trouble. TIME of the Essence in Stroke. Time Lost is Brain Lost.
WASTE NO TIME!

abdul majeedkhan

this ia an interesting study but my question is this issue was already tackled in caprie and matcah study , which showed no extra benefit of dual therapy with additional risk of gi and intracranial bleeding

Jose GROS-AYMERICH Physician, Oncology, INSS -Retired

A reminder of the beneficial effect of combined Antiplatelet therapy in TIA / Minor Ischemic Stroke, in this occassion, Clopidogrel plus Aspirin, is always welcome, but as soon as 1976, an advantage in the same disease was reported for Dipyridamole plus Aspirin. Does the subject deserve a comparative study of ASA plus Clopidogrel -or another Antiplatelet product-, vs ASA plus Dipyridamole? Would one of these therapies yield savings in Adverse Events, or in QALY or other measures of costs?

CHARLES LUTTON Physician, Neurology

The questions and controversies surronding antiplatelet therapies continue. The brain and the heart are different organs as was demonstrated with rtPA therapies. The POINT trial is anxiously awaited.

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