Risk-benefit profile of long-term dual- versus single-antiplatelet therapy among patients with ischemic stroke: a systematic review and meta-analysis

Meng Lee, Jeffrey L Saver, Keun-Sik Hong, Neal M Rao, Yi-Ling Wu, Bruce Ovbiagele
Annals of Internal Medicine 2013 October 1, 159 (7): 463-70

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.

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