Stroke Unit, Metropolitan Hospital, Piraeus.
Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens, Greece.
Curr Opin Neurol. 2021 Feb 1;34(1):45-54. doi: 10.1097/WCO.0000000000000878.
Single antiplatelet therapy represents an established treatment in secondary prevention of ischemic strokes and transient ischemic attacks (TIAs). In contrast with coronary artery disease, the use of dual antiplatelet therapy (DAPT) for secondary prevention in patients with acute cerebral ischemia (ACI) remains under debate. In this narrative review, we present and analyse the most recent findings concerning the potential efficacy and safety of DAPT therapy after ischemic strokes or TIA.
Following the publication of the three (CHANCE, POINT and THALES) large, randomized-controlled, clinical trials (RCTs) that showed efficacy of early DAPT for the secondary prevention after minor AIS or TIA, short-term DAPT use is becoming the most prevalent choice of treatment. Notably, DAPT is even more popular after AIS attributed to large artery atherosclerosis given randomized data from small RCTs supporting the use of DAPT in patients with extracranial or intracranial atherosclerosis and microembolization detected by transcranial Doppler. Recent subanalysis of data from the randomized trials aim to identify specific patient subgroups, which are determined by genetic, imaging or clinical characteristics, and for whom DAPT appears to be more beneficial. The potential role of different antiplatelet agents (aspirin, clopidogrel, ticagrelor) is also discussed.
DAPT has recently proven its efficacy for the early secondary prevention of AIS patients with minor stroke severity and high-risk TIA patients. However, the length of DAPT is still controversial, as well as the individualized selection of AIS or TIA patients with the lower risk of bleeding and with the greater benefit in prevention of ischemic cerebrovascular and cardiovascular events.
抗血小板单药治疗是缺血性卒中和短暂性脑缺血发作（TIA）二级预防的既定治疗方法。与冠状动脉疾病不同，双联抗血小板治疗（DAPT）在急性脑缺血（ACI）患者中的二级预防作用仍存在争议。在本叙述性综述中，我们提出并分析了最近关于 DAPT 治疗在缺血性卒中和 TIA 后潜在疗效和安全性的研究结果。
在三项大型随机对照临床试验（RCT）即 CHANCE、POINT 和 THALES 发表后，这些试验表明早期 DAPT 对轻度 AIS 或 TIA 后的二级预防有效，短期 DAPT 治疗的应用成为最普遍的治疗选择。值得注意的是，鉴于小型 RCT 的随机数据支持 DAPT 在颅外或颅内动脉粥样硬化以及经颅多普勒检测到的微栓塞患者中的应用，DAPT 在大动脉粥样硬化性 AIS 中的应用更为流行。最近对随机试验数据的亚组分析旨在确定特定的患者亚组，这些亚组由遗传、影像学或临床特征决定，且 DAPT 对这些亚组患者似乎更有益。还讨论了不同抗血小板药物（阿司匹林、氯吡格雷、替格瑞洛）的潜在作用。
DAPT 最近已被证明对轻度卒中严重程度和高危 TIA 患者的 ACI 早期二级预防有效。然而，DAPT 的持续时间仍存在争议，以及对出血风险较低且在预防缺血性脑血管和心血管事件方面获益更大的 AIS 或 TIA 患者进行个体化选择仍存在争议。
