. Early dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis

Circulation. 2013 Oct 8;128(15):1656-66. doi: 10.1161/CIRCULATIONAHA.113.003187. Epub 2013 Sep 12. Early dual versus mono antiplatelet therapy for acute non-cardioembolic ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis. Wong KS, Wang Y, Leng X, Mao C, Tang J, Bath PM, Markus HS, Gorelick PB, Liu L, Lin W, Wang Y. Division of Neurology, Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China (K.S.L.W., X.L., W.L.); the Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.W., L.L., Y.W.); the Hong Kong Branch of the Chinese Cochrane Center, Division of Epidemiology, School of Public Health and Primary Care, Shatin, Hong Kong SAR, China (C.M., J.T.); the Stroke Trials Unit, University of Nottingham, Nottingham, UK (P.M.W.B.); the Stroke and Dementia Research Centre, St. George's, University of London, London, UK (H.S.M.); and the Department of Translational Science and Molecular Medicine, Michigan State University College of Medicine and Saint Mary's Health Care, Grand Rapids, MI (P.B.G.).

Abstract Emerging studies suggest that early administration of dual antiplatelet therapy may be better than monotherapy for prevention of early recurrent stroke and cardiovascular outcomes in acute ischemic stroke and transient ischemic attack (TIA). We performed a meta-analysis of randomized, controlled trials evaluating dual versus mono antiplatelet therapy for acute noncardioembolic ischemic stroke or TIA.

We assessed randomized, controlled trials investigating dual versus mono antiplatelet therapy published up to November 2012 and the CHANCE trial (Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events), for efficacy and safety outcomes in adult patients with acute noncardioembolic ischemic stroke or TIA with treatment initiated within 3 days of ictus. In total, 14 studies of 9012 patients were included in the systematic review and meta-analysis. Dual antiplatelet therapy significantly reduced risk of stroke recurrence (risk ratio, 0.69; 95% confidence interval, 0.60-0.80; P<0.001) and the composite outcome of stroke, TIA, acute coronary syndrome, and all death (risk ratio, 0.71; 95% confidence interval, 0.63-0.81; P<0.001) when compared with monotherapy, and nonsignificantly increased risk of major bleeding (risk ratio, 1.35; 95% confidence interval, 0.70-2.59, P=0.37). Analyses restricted to the CHANCE Trial or the 7 double-blind randomized, controlled trials showed similar results.

For patients with acute noncardioembolic ischemic stroke or TIA, dual therapy was more effective than monotherapy in reducing risks of early recurrent stroke. The results of the CHANCE study are consistent with previous studies done in other parts of the world.