New Guidelines for Dual Antiplatelet Therapy

December 23, 2018

Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel should be initiated within 24 hours in patients with minor ischemic stroke or high-risk transient ischemic attacks (TIA) and should be continued for 10-21 days, according to a new Rapid Recommendations article published in BMJ.1

The recommendations are based upon a systematic review triggered by the results of a randomized controlled trial published in the New England Journal of Medicine in August 2018.2

The guidelines were drafted by a panel including stroke neurologists, one nurse, one health research methodologist, general internists, one physiotherapist, one vascular surgeon, one critical care clinician, and patient partners.

“Aspirin and clopidogrel have synergistic action to inhibit platelet aggregation. So it is plausible that the two drugs together may provide better secondary prevention of stroke than one,” they wrote. However, because of previous research that suggested that DAPT does not outperform single agent therapy for the prevention of recurrent stroke, the risk of hemorrhagic transformation following major strokes, and an uncertainty in the balance of benefit and harm after minor stoke, DAPT is not widely used, according to the researchers.

The review consisted of 3 randomized controlled trials that examined DAPT vs aspirin alone and included 10,447 patients. When compared with single antiplatelet therapy, DAPT was found to decrease non-fatal recurrent stroke (risk ratio 0.70), and lead to small improvements in functional disability and quality of life.

However, DAPT had little to no impact on all-cause mortality risk and incidence of myocardial infarction or recurrent transient ischemic attack and led to a small (0.2%) increase in moderate to major extracranial bleeding and a small increase (0.7%) in the risk of minor extracranial bleeding events.

—Michael Potts


1. Prasad K, Siemieniuk R, Hao Q, et al. Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline [published online Decembre 18, 2018]. BMJ. doi:

2. Johnston SC, Easton JD, Farrant M, et al., Clinical Research Collaboration, Neurological Emergencies Treatment Trials Network, and the POINT Investigators. Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA. N Engl J Med. 2018;379:215-25. doi:10.1056/NEJMoa1800410 pmid:29766750.

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