Aspirin plus clopidogrel versus aspirin alone in patients with mild-to-moderate stroke: A systematic review and meta-analysis

BACKGROUND: Studies have shown that dual antiplatelet therapy (DAPT) is superior to aspirin monotherapy in patients with minor stroke or transient ischemic attacks. However, there is limited evidence regarding the efficacy and safety of DAPT in mild-to-moderate stroke. METHODS: PubMed/MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov were searched from inception till March 2024 for published randomized controlled trials and observational studies that compared aspirin plus clopidogrel versus aspirin monotherapy in patients with mild-to-moderate stroke. R version 4.3.2 was used to calculate risk ratios (RRs) with 95% confidence intervals (95% CIs). RESULTS: A total of 4 studies reporting data for 15,173 patients were included. DAPT was associated with a non-significant trend of reduced risk of early neurological deterioration (END) (RR: 0.55, 95% CI: 0.28-1.05, P = .07) and recurrent ischemic stroke (RR: 0.65, 95% CI: 0.41-1.04, P = .07). The risk of recurrent hemorrhagic stroke (RR: 0.94, 95% CI: 0.47-1.86, P = .86), all-cause death (RR: 0.75, 95% CI: 0.52-1.08), or myocardial infarction (RR: 0.83, 95% CI: 0.45-1.54) was comparable across the two groups. DAPT was not associated with an increased risk of any bleeding event (RR: 0.70, 95% CI: 0.36-1.36). CONCLUSION: DAPT demonstrated a non-significant trend toward reduced risk of END and recurrent ischemic stroke without increasing the risk of bleeding events compared to aspirin monotherapy in patients with mild to moderate stroke. Further large-scale trials are needed to confirm these potential benefits.