Impact of dual antiplatelet therapy within 72 hours post mild ischemic stroke and transient ischemic attack: meta-analysis

OBJECTIVES: To evaluate the efficacy and safety of dual antiplatelet therapy (DAPT) initiated within 72 hours after ischemic stroke (IS) or transient ischemic attack (TIA) using network meta-analysis. METHODS: Randomized controlled trials from PubMed, Cochrane Library, and ClinicalTrials.gov (to September 30, 2024) were analyzed with R ('gemtc') and STATA. RESULTS: Twelve RCTs (50,975 patients) compared six regimens: aspirin, clopidogrel, ticagrelor, aspirin+clopidogrel, aspirin+ticagrelor, and aspirin+dipyridamole. DAPT with aspirin+clopidogrel or aspirin+ticagrelor significantly reduced recurrent stroke versus aspirin. Aspirin+dipyridamole had the highest SUCRA value, suggesting a favorable efficacy - safety balance. In patients treated within 24 hours, recurrence rates were similar across regimens.Notably, aspirin plus ticagrelor showed higher odds of major bleeding versus aspirin (OR = 4.50, 95% CI: 0.07-369.2), but the extremely wide confidence interval indicates substantial uncertainty. CONCLUSION: DAPT offers superior efficacy over aspirin alone in preventing recurrent stroke, particularly when initiated within 72 hours of symptom onset. However, the evidence regarding bleeding risk with aspirin and ticagrelor remains highly uncertain, as the estimates are imprecise with extremely wide confidence intervals, and no definitive conclusions can be drawn. Aspirin plus dipyridamole may be a safer, equally effective alternative, underscoring the need for individualized treatment based on thrombotic and hemorrhagic risks.