Key result
Discharge DAPT linked to ~134% higher favorable 90-day outcomes, but attenuates after propensity matching.
Why the study?
Carriers of CYP2C19 loss-of-function alleles exhibit reduced clopidogrel metabolism, potentially compromising dual antiplatelet therapy efficacy in acute ischemic stroke, but the impact of initial regimens versus discharge deescalation on outcomes is unclear.
Does dual antiplatelet therapy with aspirin and clopidogrel at discharge improve functional outcomes at 90 days in patients with mild to moderate acute ischemic stroke?
Cohort (n=741)
Does dual antiplatelet therapy with aspirin and clopidogrel at discharge improve functional outcomes at 90 days in patients with mild to moderate acute ischemic stroke?
Odds Ratio: 2.34 (95% CI 1.16–4.74)
p-value: p=0.018
Maintaining DAPT with aspirin and clopidogrel at discharge may be associated with favorable 90-day functional outcomes in acute ischemic stroke patients, particularly CYP2C19 LoFA carriers, but requires confirmation in randomized trials.
Supports hypothesis of benefit from discharge DAPT in mild-moderate stroke; leaves open confirmation in randomized trials, especially among CYP2C19 loss-of-function carriers.
Background Carriers of CYP2C19 loss‐of‐function alleles (LoFA) exhibit reduced metabolism of clopidogrel, potentially compromising the efficacy of dual antiplatelet therapy (DAPT) in acute ischemic stroke. We aimed to distinguish the impact of initial antiplatelet regimens from the discharge deescalation on functional outcomes. Methods The retrospective cohort study linked the prospective stroke registry with the Taiwan Precision Medicine Initiative biobank. Patients with mild to moderate acute ischemic stroke (National Institutes of Health Stroke Scale score ≤10) were included. Favorable outcomes (modified Rankin Scale score ≤1) of 2 windows were analyzed: (1) the acute window (≤48 hours), assessing outcomes at discharge, and (2) the deescalation window (discharge), assessing outcomes at 90 days. Results Among 741 patients, 463 (62.5%) were LoFA carriers. In the acute window, genotype was not associated with favorable outcomes; clinical severity (age, initial National Institutes of Health Stroke Scale score) was the dominant predictor. However, in the deescalation window, in the overall cohort, DAPT with aspirin and clopidogrel at discharge was independently associated with favorable outcomes at 90 days (odds ratio [OR], 2.34 [95% CI, 1.16–4.74]; P =0.018). Stratified analysis revealed that this benefit was driven primarily by LoFA carriers, in whom DAPT with aspirin and clopidogrel at discharge was independently associated with favorable outcomes (OR, 2.74 [95% CI, 1.17–6.38]; P =0.020). However, this association was attenuated in propensity score‐matched analyses, and there was no interaction between CYP2C19 LoFA carrier status and DAPT with aspirin and clopidogrel on favorable outcomes at 90 days. Conclusions CYP2C19 genotype did not predict early neurological deterioration. The potential long‐term clinical benefit of maintaining DAPT with aspirin and clopidogrel at discharge for LoFA carriers requires confirmation in adequately powered randomized trials.
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Liao-Ping et al. (2026) conducted a cohort in mild to moderate acute ischemic stroke (n=741). DAPT with aspirin and clopidogrel at discharge was evaluated on Favorable outcomes (modified Rankin Scale score ≤1) at 90 days (OR 2.34, 95% CI 1.16-4.74, p=0.018). DAPT with aspirin and clopidogrel at discharge was associated with favorable 90-day outcomes (OR 2.34; 95% CI 1.16-4.74), though this association was attenuated in propensity score-matched analyses.
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