Short- versus Long-term Dual Anti-platelet Therapy (DAPT) in Secondary Prevention for Ischaemic Stroke – A Network Metanalysis

Abstract

Aim: This review aimed to compare the efficacy and safety of short-term (=< 3 months) and long-term (>=1 year) dual-antiplatelet therapy (DAPT) in secondary prevention for ischaemic stroke. Methods and results: We searched MEDLINE, EMBASE (Ovid), PubMed, Cochrane Library, ClinicalTrials.gov and Google Advanced Search for randomised controlled trials. The population consisted of patients with recent ischaemic stroke or transient ischaemic attack. The intervention was DAPT with a combination of aspirin, clopidogrel and dipyridamole compared to either aspirin or clopidogrel in monotherapy. The primary outcome was the rate of all recurrent stroke (ischaemic and haemorrhagic). Secondary outcomes were ischaemic stroke, all bleeding, severe bleeding, all-cause death, cardiovascular death and myocardial infarction. Data were pooled by network metanalysis and pairwise metanalyses. Sixteen studies with 55,261 participants were included. Compared to aspirin, DAPT with aspirin clopidogrel decreased the risk of recurrent stroke (short-term OR 0.67, 95%CI 0.58-0.77; long-term OR 0.84, 95%CI 0.70- 1.01) at the expense of increased risk of bleeding (short-term OR 1.76, 95%CI 1.26-2.46; long-term OR 2.25, 95%CI 1.97-2.57). DAPT with aspirin clopidogrel and clopidogrel in monotherapy had similar long-term risk of recurrent stroke (OR 0.98, 95%CI 0.83-1.14), but DAPT was associated with increased risk of bleeding (OR 2.77, 95%CI 2.21-3.46). Network metanalysis showed that short-term aspirin clopidogrel DAPT had the best risk-benefit profile, followed by long-term aspirin clopidogrel DAPT and clopidogrel alone. Aspirin dipyridamole DAPT was less effective. Conclusion: Short-term DAPT had better risk-benefit profile than long-term DAPT.