Dual antiplatelet therapy with clopidogrel and aspirin after ischemic stroke: A review of the evidence

PURPOSE: The safety and efficacy of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel in the setting of secondary stroke prevention are reviewed. SUMMARY: Antiplatelet therapy has been shown to reduce the risk of numerous vascular events, especially in the setting of secondary prevention. DAPT with aspirin and another antiplatelet agent such as clopidogrel, prasugrel, or ticagrelor has become the main stay of acute coronary syndrome (ACS) management. The underlying pathophysiologies of ACS, ischemic stroke, and transient ischemic attack (TIA) are similar. In the setting of ACS, DAPT has clearly been shown to improve outcomes over single antiplatelet therapy for up to 12 months after the ischemic event. However, the role for DAPT in the setting of ischemic stroke and TIA is less clear. The MATCH, CHARISMA, and SPS3 studies demonstrated that DAPT was associated with increased bleeding compared with single antiplatelet therapy without an appreciable reduction in ischemic events. Early initiation of DAPT proved beneficial in reducing future ischemic events in the FASTER and CHANCE trials; however, these trials did not provide enough evidence to recommend the routine use of DAPT in secondary stroke prevention, and current guidelines recommend against such therapy. DAPT with aspirin and clopidogrel appears to be effective only for patients with minor stroke or TIA when started within 24 hours of the ischemic event and continued for a maximum of 21 days. CONCLUSION: Currently available evidence does not substantiate the widespread use of long-term aspirin with clopidogrel for the secondary prevention of ischemic stroke or TIA.