Recurrent Stroke : Dual antiplatelets

Combination of dual antiplatelets recommended:

Dual Antiplatelets Therapy	Recommended Dose	Evidence and recommendations
Aspirin + Slow release Dipyridamole	PO Aspirin : 50 – 325mg/day PO Dipyridamole SR : 400mg/day	·   This combination is superior vs aspirin or dypiridamole alone
Aspirin + Clopidogrel	PO Aspirin 100mg/day PO Clopidogrel 75mg/day	·   This dosings regimen showed an excess GI bleed and intracranial bleed ·   It is not recommended for long term secondary prevention ·   Only can be used in high risk patients who experience stroke recurrence despite monotherapy when benefit outweighs risk ·   Shown to have more benefit compared to monotherapy if initiated in early stage of minor ischemic stroke or TIA
Aspirin + Ticlopidine	No data on recommended dose	·   No further benefit if this combination used for long term secondary prevention ·   No data for use of this combination for early initiation

CONCLUSION:

• The combination of aspirin and clopidogrel might be considered for initiation within 24 hours of a minor ischemic stroke or TIA and for continuation for 21 days – American Heart Association Acute Ischemic Stroke Guideline
• Early dual antiplatelet therapy initiated early after ischemic stroke or TIA might further reduce recurrent stroke and major vascular events compared to antiplatelet monotherapy, with no significant increase in major bleeding events
• Long term dual therapy in patients with ischemic stroke or TIA administered after a high-risk period, dual antiplatelet therapy is likely to increase the harm caused by major bleeding, including intracranial hemorrhage, and its benefit of further preventing recurrent stroke as well as major ischemic events remains controversial
• If recurrent stroke despite monotherapy, dual antiplatelets can be considered when benefit outweighs risk
• Recommended therapy for secondary stroke prevention : Aspirin alone or Clopidogrel alone or Aspirin+Slow Release Dipyridamole (uptodate.com)

REFERENCES

1) American Heart Association , Executive Summary: Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack, 2014

2) Malaysian CPG Management of Ischaemic Stroke 2nd edition, 2012

3) www.uptodate.com

4) Hong K-S. Dual Antiplatelet Therapy after Noncardioembolic Ischemic Stroke or Transient Ischemic Attack: Pros and Cons. Journal of Clinical Neurology (Seoul, Korea). 2014;10(3):189-196. doi:10.3988/jcn.2014.10.3.189.