Bleeding From Antiplatelet Agents in Patients With Stroke and Transient Ischemic Attack

Since the first trials using antiplatelet agents in ischemic stroke and transient ischemic attack (TIA), there has been a consistent difficulty in balancing the benefit of a reduction of recurrent cardiovascular disease outcomes (ischemic stroke and myocardial infarction) with the risk of bleeding.1-4 This had also been an issue in acute stroke trials evaluating the effectiveness of anticoagulation and antiplatelet agents.5,6 For decades, monotherapy remained the standard of care for secondary prevention in most patients with acute ischemic stroke, but observational studies enrolling patients with TIA and minor stroke showed a high risk of recurrence at 90 days, prompting trials with dual antiplatelet agents in these patients. The publication of 3 trials demonstrating a reduction in the risk of stroke has changed our use of dual antiplatelet agents in patients with TIA and minor stroke. In these trials, each with different inclusion criteria, different drug combinations were used for different lengths of time: (1) CHANCE: clopidogrel and aspirin for 21 days, followed by clopidogrel alone for 69 days4; (2) POINT: clopidogrel and aspirin for 90 days3; and (3) THALES: ticagrelor and aspirin for 30 days.2 The risk of bleeding was different in each trial. In POINT, in particular, the risk of bleeding increased after 30 days, the same interval when the benefit seemed more muted.