Risk-Benefit Profile of Long-Term Dual-Versus Single-Antiplatelet Therapy Among Patients With Ischemic Stroke

Background: Dual-antiplatelet regimens for prevention of recurrent stroke promote antithrombotic effects but may increase the risk for hemorrhage. Purpose: To qualitatively and quantitatively examine the risk for recurrent stroke and intracranial hemorrhage (ICH) linked to long-term dual-and single-antiplatelet therapy among patients with ischemic stroke and transient ischemic attack. Data Sources: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials through March 2013 without language restrictions. Study Selection: The search identified 7 randomized, controlled trials that involved a total of 39 574 participants and reported recurrent stroke and ICH as outcome measures. Data Extraction: All data from eligible studies were independently abstracted by 2 investigators according to a standard protocol. Data Synthesis: Recurrent stroke risk did not differ between patients receiving dual-antiplatelet therapy and those receiving aspirin monotherapy (relative risk [RR], 0.89 [95% CI, 0.78 to 1.01]) or clopidogrel monotherapy (RR, 1.01 [CI, 0.93 to 1.08]). Risk for ICH did not differ between patients receiving dual-antiplatelet therapy and those receiving aspirin monotherapy (RR, 0.99 [CI, 0.70 to 1.42]) but was greater among patients receiving dual-antiplatelet therapy than among those receiving clopidogrel monotherapy (RR, 1.46 [CI, 1.17 to 1.82]). Limitation: Agents used in dual-and single-antiplatelet therapies varied across trials, and the relatively modest number of trials limited subgroup analysis. Conclusion: Compared with monotherapy, dual-antiplatelet therapy lasting more than 1 year after an index ischemic stroke or transient ischemic attack is not associated with a greater reduction in overall recurrent stroke risk. However, long-term dual-antiplatelet therapy is linked to higher risk for ICH than clopidogrel monotherapy in this patient population. Primary Funding Source: Chang Gung Memorial Hospital.