Dual versus single antiplatelet therapy in patients with nonminor ischemic stroke: a meta-analysis

Background Patients with ischemic stroke present a higher risk of stroke recurrence, neurological deterioration, and death. The benefit of dual antiplatelet therapy (DAPT) over single antiplatelet therapy (SAPT) among patients with minor ischemic stroke is well established; however, robust evidence is lacking for those with nonminor stroke. Objective To describe the benefits and risks of DAPT versus SAPT in patients with nonminor ischemic stroke. Methods We searched the PubMed, Embase, and Cochrane Library databases for articles published from inception to April 2024. Data were collected from randomized clinical trials and observational studies comparing DAPT to SAPT following nonminor ischemic stroke, defined by a score ≥ 4 on the National Institutes of Health Stroke Scale (NIHSS). Results In total, 6 studies were included, comprising 12,480 patients. The NIHSS score at baseline from the selected studies ranged from 4 to 15. There was no significant difference between DAPT and SAPT for recurrent stroke (risk ratio [RR] = 0.91; 95% confidence interval [95%CI] = 0.82–1.01; p = 0.09; I2 = 0%), ischemic stroke (RR = 0.89; 95%CI = 0.80–1.00; p = 0.05; I2 = 0%) or hemorrhagic stroke (RR = 1.23; 95%CI = 0.41-3.99; p = 0.66; I2 = 27%). Major bleeding was not significantly increased in the DAPT group compared with the SAPT group (RR = 0.87; 95%CI = 0.29–2.66; p = 0.81; I2 = 44%). The overall analysis did not show a significant difference in all-cause mortality (RR = 0.72; 95%CI = 0.50–1.02; p = 0.07; I2 = 0%). Conclusion There was no difference between DAPT and SAPT regarding recurrent stroke, ischemic stroke, hemorrhagic stroke, major bleeding, or overall mortality.