Brown Devin L, Levine Deborah A, Albright Karen, Kapral Moira K, Leung Lester Y, Reeves Mathew J, Sico Jason, Strong Brent, Whiteley William N
Stroke. 2021 Jul;52(7):e468-e479. doi: 10.1161/STR.0000000000000377. Epub 2021 May 24.
Dual antiplatelet therapy (DAPT) after ischemic stroke or transient ischemic attack may reduce recurrent stroke but also increase severe bleeding compared with single antiplatelet therapy (SAPT). The American Heart Association/American Stroke Association convened an evidence review committee to perform a systematic review and meta-analysis of the benefits and risks of DAPT compared with SAPT for secondary ischemic stroke prevention.
The Medline, Embase, and Cochrane databases were searched on December 5, 2019, to identify phase III or IV randomized controlled trials (n≥100) from December 1999 to December 2019. We calculated unadjusted relative risks (RRs) and performed meta-analyses of studies based on the duration of treatment (short [≤90 days] versus long [>90 days]).
Three short-duration randomized controlled trials were identified that enrolled mostly patients with minor stroke or high risk transient ischemic attack. In these trials, DAPT, compared with SAPT, was associated with a lower 90-day risk of recurrent ischemic stroke (pooled RR, 0.68 [95% CI, 0.55-0.83], =37.1%). There was no significant increase in major bleeding with DAPT in short-duration trials (pooled RR, 1.88 [95% CI, 0.93-3.83], =8.9%). In 2 long-duration treatment randomized controlled trials (mean treatment duration, 18-40 months), DAPT was not associated with a significant reduction in recurrent ischemic stroke (pooled RR, 0.89 [95% CI, 0.79-1.02], =1.4%), but was associated with a higher risk of major bleeding (pooled RR, 2.42 [95% CI, 1.37-4.30], =75.5%).
DAPT was more effective than SAPT for prevention of secondary ischemic stroke when initiated early after the onset of minor stroke/high-risk transient ischemic attack and treatment duration was <90 days. However, when the treatment duration was longer and initiated later after stroke or transient ischemic attack onset, DAPT was not more effective than SAPT for ischemic stroke prevention and it increased the risk of bleeding.
与单一抗血小板治疗（SAPT）相比，缺血性卒中或短暂性脑缺血发作后进行双重抗血小板治疗（DAPT）可能会降低复发性卒中的风险，但也会增加严重出血的风险。美国心脏协会/美国卒中协会召集了一个证据审查委员会，对DAPT与SAPT在二级缺血性卒中预防中的益处和风险进行系统评价和荟萃分析。
于2019年12月5日检索Medline、Embase和Cochrane数据库，以识别1999年12月至2019年12月期间的III期或IV期随机对照试验（n≥100）。我们计算了未经调整的相对风险（RRs），并根据治疗持续时间（短[≤90天]与长[>90天]）对研究进行了荟萃分析。
确定了三项短期随机对照试验，这些试验纳入的大多是轻度卒中或高危短暂性脑缺血发作的患者。在这些试验中，与SAPT相比，DAPT与90天复发性缺血性卒中风险较低相关（合并RR，0.68[95%CI，0.55 - 0.83]，P = 37.1%）。在短期试验中，DAPT导致的严重出血没有显著增加（合并RR，1.88[95%CI，0.93 - 3.83]，P = 8.9%）。在两项长期治疗随机对照试验（平均治疗持续时间为18 - 40个月）中，DAPT与复发性缺血性卒中的显著降低无关（合并RR，0.89[95%CI，0.79 - 1.02]，P = 1.4%），但与严重出血风险较高相关（合并RR，2.42[95%CI，1.37 - 4.30]，P = 75.5%）。
在轻度卒中/高危短暂性脑缺血发作后早期开始治疗且治疗持续时间<90天时，DAPT在预防二级缺血性卒中方面比SAPT更有效。然而，当治疗持续时间较长且在卒中或短暂性脑缺血发作后较晚开始时，DAPT在预防缺血性卒中方面并不比SAPT更有效，且会增加出血风险。
