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Analysis

Acute dual antiplatelet therapy for minor ischaemic stroke or transient ischaemic attack

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l895 (Published 28 February 2019) Cite this as: BMJ 2019;364:l895

Rapid recommendation

Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke

  1. Yongjun Wang, professor1234,
  2. S Claiborne Johnston, professor5,
  3. Philip M Bath, professor6,
  4. James C Grotta, professor7,
  5. Yuesong Pan, researcher1234,
  6. Pierre Amarenco, professor8,
  7. Yilong Wang, professor1234,
  8. Tabassome Simon, professor91011,
  9. Jong Sung Kim, professor12,
  10. Jiann-Shing Jeng, professor13,
  11. Liping Liu, professor1234,
  12. Yi Lin, associate professor14,
  13. Ka Sing Lawrence Wong, professor15,
  14. David Wang, professor1617,
  15. Hao Li, professor1234
  1. 1Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
  2. 2China National Clinical Research Center for Neurological Diseases, Beijing, China
  3. 3Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
  4. 4Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
  5. 5Dean’s Office, Dell Medical School, University of Texas at Austin, Austin, TX, USA
  6. 6Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
  7. 7Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX, USA
  8. 8Department of Neurology and Stroke Center, Bichat University Hospital and Paris-Diderot, Sorbonne University, Paris, France
  9. 9Department of Clinical Pharmacology and Clinical Research Platform of East of Paris, Assistance Publique-Hôpitaux de Paris, Paris, France
  10. 10Department of Clinical Pharmacology, Sorbonne Université, Paris, France
  11. 11French Alliance for Cardiovascular Clinical Trials, Paris, France
  12. 12Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, South Korea
  13. 13Department of Neurology and Stroke Center, National Taiwan University Hospital, Taipei, Taiwan
  14. 14Department of Neurology and Institute of Neurology, First Affiliated Hospital, Fujian Medical University, Fuzhou, China
  15. 15Division of Neurology, Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
  16. 16Illinois Neurological Institute Stroke Network, OSF Healthcare System, Peoria, IL, USA
  17. 17Department of Neurology, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
  1. Correspondence to: Yongjun Wang yongjunwang{at}ncrcnd.org.cn

Yongjun Wang and colleagues discuss recent evidence for using dual antiplatelet therapy to reduce recurrence of stroke or transient ischaemic attack

Key messages

  • Recent research on antiplatelet therapy has advanced the knowledge of early, intensive treatment for recurrent stroke in minor ischaemic stroke or transient ischaemic attack

  • In patients with high risk, non-disabling ischaemic cerebrovascular events, including minor stroke and transient ischaemic attack, short term dual antiplatelet therapy should be given within 24 hours after the onset of symptoms and as early as possible

  • Further studies are needed to evaluate antiplatelet strategies, explore whether dual antiplatelet therapy could benefit broader patient population, and improve adherence of the recommended antiplatelet therapy

The risk of recurrent stroke and other vascular events is high in the first few weeks after index minor ischaemic stroke and high risk transient ischaemic attack (5-11.7%).12 Dual antiplatelet therapy (DAPT), comprising clopidogrel and aspirin, is an effective strategy for reducing recurrence.1 An expert panel from the MAGIC group (http://magicproject.org/) recently produced a strong rapid recommendation in The BMJ for starting DAPT within 24 hours of symptom onset and continuing for 10-21 days in patients with minor stroke or transient ischaemic attack.3 The evidence for this came from a systematic review and meta-analysis of published clinical trials.4 Most current international guidelines,5678 but not all,9 recommend early (within 24 hours) and short term (a duration of 21 days or 21-30 days) DAPT in patients with minor stroke or transient ischaemic attack (table 1).

View this table:
Table 1

Current recommendations on antiplatelet therapy for patients with minor stroke or TIA

Questions remain regarding choice of antiplatelet strategy, possibility of safe expansion of DAPT to a broader patient population, and adherence of patients to recommended antiplatelet therapy in clinical practice.

Recent trials

In the past five years, trials on acute …

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