Efficacy and safety of dual antiplatelet therapy in the elderly for stroke prevention: a systematic review and meta-analysis

Background and purposeThere is a lack of age-specific evidence regarding the efficacy and safety of dual antiplatelet therapy (DAPT). A systematic review and meta-analysis was conducted for dual versus mono antiplatelet therapy in elderly patients with ischaemic stroke (IS) or transient ischaemic attack (TIA). MethodsPubMed, Embase and the Cochrane Central Register of Controlled Trials were searched for relevant studies. Risk ratios (RRs) for the outcomes of stroke recurrence, major bleeding and intracranial bleeding were calculated based on the DerSimonian and Laird random effects model. Subgroup analyses were conducted. ResultsIn seven multicentre, randomized controlled trials comprising 24873 patients with IS or TIA, aged 65years or older, a significant reduction in the risk of recurrent stroke was observed using DAPT in comparison with aspirin monotherapy [RR 0.79, 95% confidence interval (95% CI) 0.69-0.91; P=0.001]. DAPT was not associated with a significant reduction in recurrent stroke compared with clopidogrel monotherapy (RR 1.01, 95% CI 0.93-1.10; P=0.800). In addition, the results from two studies showed that DAPT significantly increased the risk of major bleeding and intracranial bleeding in elderly patients over younger patients (RR 2.18, 95% CI 1.02-4.69; and RR 2.13, 95% CI 1.18-3.86, respectively). ConclusionsFor stroke prevention in elderly patients with IS or TIA, DAPT is superior to aspirin monotherapy but appears to be equivalent to clopidogrel monotherapy, and is accompanied by an increased risk of bleeding. The balance between the benefits and risks of DAPT is important to consider when choosing antiplatelet strategy.