Early initiation of dual antiplatelet therapy within 24 hours reduced the risk of adverse events by 26% compared to monotherapy in patients with minor stroke or high-risk TIA.
Does in-hospital initiation of dual antiplatelet therapy reduce the composite of recurrent stroke, myocardial infarction, and death within 90 days in patients with minor noncardioembolic ischemic stroke or high-risk TIA compared to monotherapy?
Early initiation of DAPT within 24 hours provides the greatest clinical benefit for minor stroke or high-risk TIA, with efficacy declining progressively and crossing the null at approximately 42 hours.
Absolute Event Rate: 0% vs 0%
BACKGROUND: Dual antiplatelet therapy (DAPT) is recommended within 24 hours for patients with minor ischemic stroke or high-risk transient ischemic attack. However, the optimal timing for initiating DAPT remains unclear. METHODS: From a prospective multicenter cohort involving 20 stroke centers between January 2011 and April 2023, patients with minor noncardioembolic ischemic stroke (National Institutes of Health Stroke Scale score ≤5) or high-risk transient ischemic attack who presented within 7 days of symptom onset were included. We evaluated outcomes based on in-hospital initiation of DAPT versus monotherapy (aspirin or clopidogrel alone). The primary outcome was a composite of recurrent stroke, myocardial infarction, and death within 90 days. Patients were grouped by time from symptom onset to hospital arrival: 0 to 24 hours, 24 to 72 hours, and >72 hours. Time-to-treatment effects were analyzed using Cox proportional hazards models, with inverse probability of treatment weighting based on propensity scores. The adjusted models incorporated demographic factors, baseline clinical characteristics, vascular risk factors, stroke subtype, relevant arterial status, and prior antiplatelet use. RESULTS: Among the 41 530 patients (mean age, 66.3 years; 25 771 62% male), 25 112 (60.5%) received DAPT. The 90-day primary outcome occurred in 2663 (10.7%) of the DAPT group versus 1900 (11.6%) in the monotherapy group (hazard ratio, 0.82 95% CI, 0.77–0.87). The benefit of DAPT was most pronounced when initiated within 24 hours (hazard ratio, 0.74 95% CI, 0.69–0.79). No significant benefit was observed when DAPT was initiated between 24 and 72 hours (hazard ratio, 1.00 95% CI, 0.88–1.15), and a higher risk was suggested for initiation beyond 72 hours (hazard ratio, 1.25 95% CI, 1.01–1.55). Time-dependent analysis showed a benefit crossing the null at ≈42 hours. CONCLUSIONS: Early initiation of DAPT was associated with the greatest clinical benefit, consistent with current guideline recommendations. The therapeutic effect appeared to decline progressively beyond this period, with an estimated threshold around 42 hours.
Shin et al. (Fri,) reported a other. Early initiation of dual antiplatelet therapy within 24 hours reduced the risk of adverse events by 26% compared to monotherapy in patients with minor stroke or high-risk TIA.