Several studies have demonstrated no benefits with the use of dual anti-platelet therapy for patients with stroke in reducing the recurrence of ischemic attack. 1-4
The CHANCE trial, a randomized, double blind, placebo controlled, multi-center Chinese study was recently published. The study included a total of 5170 patients who were recently diagnosed with minor stroke or transient ischemic attack (TIA). Patients were recruited within 24 hours. The authors showed that early initiation of dual antiplatelet therapy decreased the incidence of stroke (either ischemic or hemorrhagic) without increasing the incidence of bleeding.5
Patients in this study were randomly assigned within 24 hours of symptoms to either aspirin plus placebo for 90 days or aspirin for 21 days plus clopidogrel for 90 days. Patients in the clopidogrel–aspirin arm received loading dose 300 mg clopidogrel on day 1 then 75 mg daily from day 2 through 90, and all patients received aspirin in a dose of 75 mg daily in days 2 through 21, and placebo aspirin on days 22 through 90. Patients in the aspirin group received 75 mg aspirin daily on days 2 through 90 with a placebo version of clopidogrel on days 1 through 90. The study’s primary efficacy outcome was new stroke events (ischemic or hemorrhagic) at 90 days and the primary safety outcome was moderate to severe bleeding events. The primary efficacy outcome occurred significantly less in the combination group (8.2%) vs. aspirin group (11.7%) (hazard ratio [HR],0.68; 95% confidence interval [CI], 0.57 to 0.81; p<0.001), the absolute risk reduction (ARR) is 3.5% and number need to treat (NNT) to prevent one stroke event in 90 days is 29 patients. The rate of moderate to severe bleeding was 0.3% in both groups and the rate of any bleeding events was 2.3% in the combination group compared with 1.6% in the aspirin group (HR, 1.41; 95% CI, 0.95 to 2.10; p = 0.09).
Although these results seem promising, a limitation to this study is it was only conducted in Chinese patients who may have pharmacogenomonic variations that affect the response to these drugs. This would reduce the generalizeability of the study to other populations.6 The good news is that there is an ongoing study “The Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT)"7 that will give a better judgment about the benefit of early initiation of dual anti-platelet therapy for a short time for stroke patients. Therefore, we shall hold our horses for now and wait for the POINT to get to the point.
1. Diener H-C, Bogousslavsky J, Brass LM, et al; MATCH Investigators. Aspirin and clopidogrel compared with clopidogrel alone after ischemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomized, double-blind, placebo-controlled trial. Lancet. 2004;364:331–337.
2. SPS3 Investigators; Benavente OR, Hart RG, McClure LA, et al. Effects of clopidogrel added to aspirin inpatients with recent lacunar stroke. N Engl J Med. 2012;367:817–825.
3. Bhatt DL, Fox KA, Hacke W, et al; CHARISMA Investigators. Clopidogrel and aspirin versus aspirin alone for the prevention of atherothrombotic events. N Engl J Med. 2006;354:1706–1717.
4. Kennedy J, Hill MD, Ryckborst KJ, et al; FASTER Investigators. Fast assessment of stroke and transient ischaemic attack to prevent early recurrence (FASTER): a ...