Practice Guidelines

Dual Antiplatelet Therapy for High-Risk TIA and Minor Stroke: BMJ Rapid Recommendation


Am Fam Physician. 2019 Sep 15;100(6):378-379.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• A 10- to 21-day course of dual antiplatelet therapy reduces stroke recurrence and improves quality of life after mild stroke or high-risk TIA.

• Low-dose aspirin and a 300-mg loading dose of clopidogrel should be started as soon as imaging rules out hemorrhage.

• After 10 to 21 days of daily low-dose aspirin and clopidogrel, 75 mg, the patient should be switched to a single antiplatelet drug.

From the AFP Editors

Dual antiplatelet therapy after stroke has not previously been shown to improve outcomes over a single agent. Based on a recent randomized controlled trial followed by a systematic review, the BMJ and MAGIC group concluded that dual antiplatelet therapy use for a limited period after mild stroke is beneficial. The combination of low-dose aspirin and clopidogrel (Plavix) reduces recurrent stroke and disability compared with aspirin alone when started as soon as possible after a high-risk transient ischemic attack (TIA) or minor ischemic stroke without persistent disabling neurologic deficit and continued for 10 to 21 days.

The severity of TIA can be determined using the ABCD2 score (Table 1). Dual antiplatelet therapy is recommended for an ABCD2 score of 4 or greater. Minor stroke can be identified by a National Institutes of Health (NIH) Stroke Scale score of 3 or less. The risk of recurrence after minor stroke is similar to that after a high-risk TIA. The NIH Stroke Scale ranges from 0 to 42 and is based on measures of motor and sensory function, language and speech, vision, level of consciousness and attention, and neglect. Dual antiplatelet therapy should be started as soon as brain imaging rules out intracranial hemorrhage. Although trials used various dosing strategies, members of the BMJ and MAGIC panel recommend a loading dose of 300 mg of clopidogrel followed by 75 mg daily, and low-dose aspirin at 75 to 81 mg daily. The aspirin should be taken whole without food, but clopidogrel can be crushed or split and taken with or without food.

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ABCD2 Score for Transient Ischemic Attack



1 point if > 60 years

Blood pressure

1 point if > 140/90 mm Hg

Clinical signs

1 point if speech disturbance only

2 points if unilateral weakness

Diabetes mellitus

1 point if present


1 point if 10 to 59 minutes

2 points if ≥ 1 hour


ABCD2 Score for Transient Ischemic Attack



1 point if > 60 years

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of Practice Guidelines published in AFP is available at



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