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Re: Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline
This rapid recommendation is a welcome addition to existing guidelines, concisely written and easy to implement in clinical practice. However, while suggesting a reasonable standard loading dose of clopidogrel, it leaves the age-old matter of aspirin dosing unnecessarily open. There were two large trials (IST and CAST) using 300 mg and 160 mg respectively (1) (2); and there are at least some suggestions that up to 100 mg may not be sufficient for all, esp. overweight patients in long-term secondary prevention (3). So why should we not keep it simple and adapt a standard asprin-loading dose of 300 mg and continue with either 100 mg or 150 mg until discharge ?
(1) The International Stroke Trial (IST): a randomised trial of aspirin, subcutaneous heparin, both, or neither among 19435 patients with acute ischaemic stroke. International Stroke Trial Collaborative Group;
Lancet. 1997 May 31;349(9065):1569-81
(2) CAST: randomised placebo-controlled trial of early aspirin use in 20,000 patients with acute ischaemic stroke. CAST (Chinese Acute Stroke Trial) Collaborative Group; Lancet. 1997 Jun 7;349(9066):1641-9
(3) Peter M Rothwell et. al.; Effects of aspirin on risks of vascular events and cancer according to bodyweight and dose: analysis of individual patient data from randomised trials; Lancet 2018; 392: 387–99