Randomised controlled trials of dual antiplatelet therapy versus aspirin in patients with stroke or transient ischaemic attack: an updated meta-analysis

INTRODUCTION: We explored the efficacy and safety of dual antiplatelet therapy (DAPT) for individuals diagnosed with stroke or transient ischaemic attack (TIA), incorporating the latest insights from randomised controlled trials (RCTs). The emerging evidence surrounding DAPT in stroke and TIA plays a pivotal role in guiding clinical decisions. METHODS: Our study included five RCTs (INSPIRES, THALES, POINT, CHANCE, FASTER) on DAPT (aspirin + P2Y12 inhibitor) initiated within 72 hours of acute stroke or TIA, which evaluated DAPT efficacy and safety over 21-90 days, focusing on new strokes and major bleeding. Secondary outcomes included cardiovascular events and recurrent strokes. Pooled odds ratios (OR) were computed using a random effects model. RESULTS: The five RCTs involved 27,559 patients. Our analysis showed that DAPT significantly reduced stroke recurrence (OR 0.75; 95% confidence interval CI 0.68-0.82; P <0.001, I 2 = 0%) but increased major bleeding risk (OR 2.20; 95% CI 1.38-3.51, P = 0.0009, I 2 = 30%). It lowered major adverse cardiovascular events (OR 0.76; 95% CI 0.67-0.85, P < 0.001, I 2 = 5%) and recurrent ischaemic events (OR 0.73; 95% CI 0.66-0.80, P < 0.001, I 2 = 0%), but raised haemorrhagic stroke risk (OR 2.09; 95% CI 1.14-3.84, P = 0.02, I 2 = 8%). CONCLUSION: Dual antiplatelet therapy - a combination of aspirin with either ticagrelor or clopidogrel - initated within 72 hours of a high-risk TIA or mild moderate ischaemic stroke is superior to aspirin alone in reducing the risk of recurrent stroke. However, DAPT comes with a higher risk of major bleeding.