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Am Fam Physician. 2021;104(5):online

Clinical Question

Is dual antiplatelet therapy, started within 24 hours of symptom onset, more effective than aspirin in preventing subsequent cerebrovascular events in patients who have had acute stroke or transient ischemic attack (TIA)?

Bottom Line

If the authors have found all the relevant studies, administering dual antiplatelet therapy within 24 hours of a mild to moderate stroke or TIA is more effective than aspirin at decreasing recurrent stroke over the subsequent 90 days. There is a low overall risk of major bleeding, but it is significantly higher with dual antiplatelet therapy than with aspirin. (Level of Evidence = 1a–)


The authors searched several databases and a trial registry to identify randomized trials that included adult patients with acute stroke or TIA who were randomized to receive antiplatelet therapy within 24 hours of symptom onset. The included studies compared the safety and efficacy of dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor such as clopidogrel [Plavix], ticagrelor [Brilinta], or prasugrel [Effient]) with aspirin alone. The authors excluded patients with presumed cardioembolic strokes and patients who were not already using anticoagulation. The authors do not describe a formal assessment of study quality. They included four studies with a total of 21,459 patients: three studies evaluated clopidogrel and one evaluated ticagrelor.

Although all the trials enrolled patients with mild to moderate stroke (National Institutes of Health Stroke Scale score 0 to 5) or TIA, the distribution of patients with TIA varied from 2.6% to 43.2%. Therapy duration ranged from 21 to 90 days, and the longest follow-up period was 90 days. The rate of recurrent stroke was lower in patients treated with dual antiplatelet therapy (5.8% vs. 7.7%; number needed to treat = 53; 95% CI, 40 to 83), but the rate of major bleeding was also higher in those receiving dual antiplatelet therapy (0.66% vs. 0.27%; number needed to harm = 256; 95% CI, 172 to 476). There was no difference between groups in all-cause mortality. There were variable degrees of heterogeneity among the data.

Study design: Meta-analysis (randomized controlled trials)

Funding source: Unknown/not stated

Setting: Various (meta-analysis)

Reference: Bhatia K, Jain V, Aggarwal D, et al. Dual antiplatelet therapy versus aspirin in patients with stroke or transient ischemic attack: meta-analysis of randomized controlled trials. Stroke. 2021;52(6):e217–e223.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

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