Bhatia Kirtipal, Jain Vardhmaan, Aggarwal Devika, Vaduganathan Muthiah, Arora Sameer, Hussain Zeeshan, Uberoi Guneesh, Tafur Alfonso, Zhang Cen, Ricciardi Mark, Qamar Arman
Department of Medicine, Icahn School of Medicine at Mount Sinai, NY (K.B.).
Department of Medicine, Cleveland Clinic, Cleveland, OH (V.J.).
Stroke. 2021 Jun;52(6):e217-e223. doi: 10.1161/STROKEAHA.120.033033. Epub 2021 Apr 27.
Antiplatelet therapy is key for preventing thrombotic events after transient ischemic attack or ischemic stroke. Although the role of aspirin is well established, there is emerging evidence for the role of short-term dual antiplatelet therapy (DAPT) in preventing recurrent stroke.
We conducted a systematic review and study-level meta-analyses of randomized controlled trials comparing outcomes of early initiation of short-term DAPT (aspirin+P2Y12 inhibitor for up to 3 months) versus aspirin alone in patients with acute stroke or transient ischemic attack. Primary efficacy outcome was risk of recurrent stroke and primary safety outcome was incidence of major bleeding. Secondary outcomes studied were risk of any ischemic stroke, hemorrhagic stroke, major adverse cardiovascular events, and all-cause death. Pooled risk ratios (RRs) and CIs were calculated using a random-effects model.
Four trials with a total of 21 459 patients were included. As compared to aspirin alone, DAPT had a lower risk of recurrent stroke (RR, 0.76 [95% CI, 0.68–0.83]; P<0.001; I2=0%) but a higher risk of major bleeding events (RR, 2.22 [95% CI, 1.14–4.34], P=0.02, I2=46.5%). Patients receiving DAPT had a lower risk of major adverse cardiovascular events (RR, 0.76 [95% CI, 0.69–0.84], P<0.001, I2=0%) and recurrent ischemic events (RR, 0.74 [95% CI, 0.67–0.82], P<0.001, I2=0%).
As compared to aspirin alone, short-term DAPT within 24 hours of high-risk transient ischemic attack or mild-moderate ischemic stroke reduces the risk of recurrent stroke at the expense of higher risk of major bleeding.
抗血小板治疗是预防短暂性脑缺血发作或缺血性卒中后血栓形成事件的关键。虽然阿司匹林的作用已得到充分确立，但越来越多的证据表明短期双重抗血小板治疗（DAPT）在预防复发性卒中方面的作用。
我们对随机对照试验进行了系统评价和研究水平的荟萃分析，比较急性卒中或短暂性脑缺血发作患者早期开始短期DAPT（阿司匹林+P2Y12抑制剂，长达3个月）与单独使用阿司匹林的结局。主要疗效结局是复发性卒中风险，主要安全性结局是大出血发生率。研究的次要结局是任何缺血性卒中、出血性卒中、主要不良心血管事件和全因死亡风险。使用随机效应模型计算合并风险比（RRs）和置信区间（CIs）。
纳入了4项试验，共21459例患者。与单独使用阿司匹林相比，DAPT复发性卒中风险较低（RR，0.76[95%CI，0.68–0.83]；P<0.001；I2=0%），但大出血事件风险较高（RR，2.22[95%CI，1.14–4.34]，P=0.02，I2=46.5%）。接受DAPT的患者主要不良心血管事件风险较低（RR，0.76[95%CI，0.69–0.84]，P<0.001，I2=0%）和复发性缺血事件风险较低（RR，0.74[95%CI，0.67–0.82]，P<0.001，I2=0%）。
与单独使用阿司匹林相比，高危短暂性脑缺血发作或轻中度缺血性卒中24小时内的短期DAPT可降低复发性卒中风险，但以大出血风险较高为代价。
