Practice Guidelines

Dual Antiplatelet Therapy for Loftier-Hazard TIA and Modest Stroke: BMJ Rapid Recommendation

Key Points for Practice

• A 10- to 21-day course of dual antiplatelet therapy reduces stroke recurrence and improves quality of life afterwards mild stroke or loftier-run a risk TIA.

• Depression-dose aspirin and a 300-mg loading dose of clopidogrel should be started every bit presently as imaging rules out hemorrhage.

• Later on 10 to 21 days of daily depression-dose aspirin and clopidogrel, 75 mg, the patient should exist switched to a single antiplatelet drug.

From the AFP Editors

Dual antiplatelet therapy after stroke has not previously been shown to improve outcomes over a single agent. Based on a recent randomized controlled trial followed by a systematic review, the BMJ and MAGIC group concluded that dual antiplatelet therapy use for a limited period afterward mild stroke is beneficial. The combination of depression-dose aspirin and clopidogrel (Plavix) reduces recurrent stroke and disability compared with aspirin alone when started every bit soon as possible after a high-risk transient ischemic attack (TIA) or minor ischemic stroke without persistent disabling neurologic deficit and connected for 10 to 21 days.

The severity of TIA tin exist adamant using the ABCD2 score (Table ane). Dual antiplatelet therapy is recommended for an ABCD2 score of iv or greater. Small-scale stroke tin be identified past a National Institutes of Health (NIH) Stroke Calibration score of 3 or less. The adventure of recurrence after minor stroke is similar to that after a loftier-risk TIA. The NIH Stroke Scale ranges from 0 to 42 and is based on measures of motor and sensory function, language and speech communication, vision, level of consciousness and attending, and neglect. Dual antiplatelet therapy should be started as shortly as encephalon imaging rules out intracranial hemorrhage. Although trials used various dosing strategies, members of the BMJ and MAGIC panel recommend a loading dose of 300 mg of clopidogrel followed by 75 mg daily, and low-dose aspirin at 75 to 81 mg daily. The aspirin should exist taken whole without nutrient, simply clopidogrel can exist crushed or separate and taken with or without food.

TABLE 1.

ABCD2 Score for Transient Ischemic Assail

Criteria Score

Age

1 indicate if > 60 years

Blood pressure

1 point if > 140/90 mm Hg

Clinical signs

1 bespeak if speech disturbance just

2 points if unilateral weakness

Diabetes mellitus

one point if present

Elapsing

1 point if 10 to 59 minutes

ii points if ≥ 1 hour

When imaging will be performed more than 24 hours later symptom onset, handling should be initiated as presently as minor ischemic stroke or transient TIA is diagnosed by a physician with intent to prototype equally soon as possible.

Evidence indicates that there is no comeback in stroke-related outcomes and increased take chances of bleeding with continuation of dual anti-platelet therapy in the long term (22 to xc days) after stroke. Patients, however, should probable continue to take i amanuensis for the forseeable hereafter. Dual antiplatelet therapy should not exist used in patients experiencing a major stroke considering of the associated increased take a chance of intracranial bleeding.

Background

The systematic review on which this recommendation was based included three randomized controlled trials evaluating dual antiplatelet therapy compared with aspirin monotherapy in more than 10,000 patients. These studies identified that dual therapy decreased nonfatal recurrent strokes (number needed to treat [NNT] = 53), moderate to severe disability (NNT = 72), and poor quality of life (NNT = 77). Dual antiplatelet therapy had no effect on all-cause mortality or the incidence of myocardial infarction or recurrent TIA, and had some associated harms of pocket-size (number needed to harm [NNH] = 143) and moderate to major (NNH = 500) extracranial bleeding.

The panel believed that well-nigh patients would value preventing another stroke over experiencing bleeding and thus opt for dual therapy over monotherapy. They likewise believed most patients would opt for shorter treatment duration because of the similar benefits provided, with less associated harm.

Editor'south Note: The numbers needed to treat and to harm were calculated by the AFP medical editors based on raw data provided in the original BMJ article.

Guideline source: The BMJ and MAGIC Group

Evidence rating system used? Aye

Systematic literature search described? Yes

Guideline developed past participants without relevant financial ties to manufacture? Yes

Recommendations based on patient-oriented outcomes? Yep

Published source: BMJ. December 2018;363:k5130

Available at: https://www.bmj.com/content/363/bmj.k5130.long

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Coverage of guidelines from other organizations does non imply endorsement past AFP or the AAFP.

This serial is coordinated by Sumi Sexton, Medico, Editor-in-Chief.

A collection of Practice Guidelines published in AFP is available at https://world wide web.aafp.org/afp/practguide.

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