The art of delivering evidence-based dual antiplatelet therapy

Clopidogrel and ASA initiated within 24 hours of a minor stroke (ie, National Institutes of Health Stroke Score/Scale <4 [www.ninds.nih.gov/sites/default/files/NIH_Stroke_Scale_Booklet.pdf]³⁴) or TIA and continued for a total of 21 days of DAPT, followed by clopidogrel alone to complete 90 days of treatment, have been demonstrated to reduce the risk of recurrent ischemic stroke compared to ASA alone without increasing the risk of bleeding (SOR: B).³⁵

In a multinational trial of DAPT, stroke risk was reduced at 90 days after TIA or mild stroke but bleeding risk was higher, compared to ASA alone; continuing DAPT for 90 days might explain the higher risk of bleeding.³⁶

For secondary prevention of stroke in patients with aspirin allergy, monotherapy with clopidogrel is an option, but use of clopidogrel or ticagrelor is not superior to ASA.^37,38 Therefore, there may be benefit, in patients with TIA or minor stroke, to continue DAPT beyond 21 days but at the risk of bleeding complications. (SOR: A: Harm).^33,34

Based on these data, the best duration of DAPT after TIA or mild stroke is likely 21 to 28 days.

When a patient requires VKA therapy, the benefit of using DAPT to further reduce ischemic cerebrovascular or cardiovascular events is unknown (SOR: C). In the setting of atrial fibrillation with unstable angina or CAD stent implantation, however, therapy with DAPT plus a VKA can be considered—but with increased risk of nonfatal and fatal bleeding.³⁹

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