After Stroke, DAPT Benefits Some More Than Others

Infarction patterns may aid in predicting the risk of recurrent stroke within 3 months of a noncardioembolic transient ischemic attack (TIA) or minor ischemic stroke, and patients with multiple acute infarctions experienced the most benefits from dual antiplatelet therapy, according to recent research.

In a substudy of the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) randomized clinical trial, researchers assessed 1342 patients with noncardioembolic TIA or minor stroke from October 1, 2009, to July 30, 2012.
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Patients were categorized into 1 of 3 groups based on infarction patterns, which were determined via diffusion-weighted imaging: multiple acute infarctions (MAIs), single acute infarction (SAI), and no acute infarction (NAI).

A total of 1089 patients were included in the final analysis. Following adjustment, results showed that patients with MAI (hazard ratio [HR] 5.8) and SAI (HR 3.9) had higher odds of recurrent stroke vs those with NAI at 3-month follow-up.

Among patients with MAIs, stroke recurrence occurred in 15 who were treated with clopidrogel plus aspirin and in 25 treated with placebo plus aspirin (HR 0.5). In patients with SAI, 24 patients in each treatment group had stroke recurrence (HR 1.1)

For patients with NAI, stroke recurrence occurred in 3 who received clopidrogel plus aspirin and 2 who received placebo plus aspirin (HR 1.1).

Moderate to severe bleeding risk did not increase with clopidogrel plus aspirin use, the researchers noted.

“Infarction patterns can efficiently stratify the risk of recurrent stroke within 3 months of noncardioembolic TIA or minor ischemic stroke,” the researchers concluded.

“Patients with MAIs received the most pronounced clinical benefit from dual antiplatelet therapy without increasing the risk of moderate to severe bleeding,” they continued. “However, even if after dual antiplatelet treatment, patients with MAIs still had a risk of stroke recurrence as high as those with SAI.”

—Christina Vogt

Reference:

Jing J, Meng X, Zhao X, et al. Dual antiplatelet therapy in transient ischemic attack and minor stroke with different infarction patterns: subgroup analysis of CHANCE randomized clinical trial [Published online March 26, 2018]. JAMA Neurol. doi:10.1001/jamaneurol.2018.0247.