Be Ready With Answers About DAPT After a Minor Stroke

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.

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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 of 7 points.

Now a new study examines starting DAPT within 72 hours for stroke with slightly worse symptoms, an NIHSS score of 5 or less...or high-risk TIA.

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.

Guide use of DAPT to reduce recurrent stroke risk in select cases.

For example, consider expanding order set criteria for short course DAPT to include patients with an NIHSS score up to 5, rather than 3.

But avoid DAPT with more severe or cardioembolic strokes...or for those who get 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 of 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 300 up to 325 mg of aspirin...then step down to clopidogrel 75 mg/day plus aspirin 81 mg/day.

Be aware, ticagrelor 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 costs about $15/day...versus less than $1/day for clopidogrel.

Verify that DAPT orders stop 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.

At discharge, provide clear instructions about when patients will transition to ONE long-term antiplatelet...generally aspirin 81 mg/day.

See our chart, Antiplatelets for Recurrent Ischemic Stroke, for pros and cons of the various regimens. And use our Acute Ischemic Stroke Pharmacotherapy Checklist for other important discharge meds.

Key References

  • Gao Y, Chen W, Pan Y, et al; INSPIRES Investigators. Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke. N Engl J Med. 2023 Dec 28;389(26):2413-2424.
  • Kim AS. Extending Dual Antiplatelet Therapy for TIA or Stroke. N Engl J Med. 2023 Dec 28;389(26):2478-2479.
  • 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 Jul;52(7):e364-e467.
Hospital Pharmacist's Letter. May 2024, No. 400502

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