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Dual Antiplatelet Therapy with Aspirin and Clopidogrel for Acute High Risk

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Dual Antiplatelet Therapy with Aspirin and Clopidogrel for Acute High Risk RAPID RECOMMENDATIONS BMJ: first published as 10.1136/bmj.k5130 on 18 December 2018. Downloaded from Dual antiplatelet therapy with aspirin and clopidogrel for acute high risk transient ischaemic attack and minor ischaemic stroke: a clinical practice guideline Kameshwar Prasad,1 Reed Siemieniuk,2 3 Qiukui Hao,2 4 Gordon Guyatt,2 5 Martin O’Donnell,6 Lyubov Lytvyn,2 Anja Fog Heen,7 Thomas Agoritsas,2 8 Per Olav Vandvik,7 9 Sankar Prasad Gorthi,10 Loraine Fisch,11 Mirza Jusufovic,12 Jennifer Muller,13 14 Brenda Booth,13 Eleanor Horton,15 Auxiliadora Fraiz, Jillian Siemieniuk,16 Awah Cletus Fobuzi,17 Neelima Katragunta,18 Bram Rochwerg2 5 Full author details can be found at What is the role of dual antiplatelet therapy after high and their patients in adherence with standards for trust- the end of the article risk transient ischaemic attack or minor stroke? Specifi- worthy guidelines and the GRADE system.3-5 A panel free Correspondence to: cally, does dual antiplatelet therapy with a combination of financial conflicts of interest, and including patients, B Rochwerg [email protected] of aspirin and clopidogrel lead to a greater reduction in drafted the recommendations. We have managed intel- Cite this as: BMJ 2018;363:k5130 recurrent stroke and death over the use of aspirin alone lectual interests. doi: 10.1136/bmj.k5130 when given in the first 24 hours after a high risk transient Box 1 shows all of the articles and evidence linked This BMJ Rapid Recommendation ischaemic attack or minor ischaemic stroke? An expert in this Rapid Recommendation package. The core info- article is one of a series that panel produced a strong recommendation for initiating graphic provides an overview of the absolute benefits provides clinicians with trustworthy recommendations for potentially dual antiplatelet therapy within 24 hours of the onset of and harms for DAPT compared with aspirin monotherapy. practice changing evidence. symptoms, and for continuing it for 10-21 days. Current BMJ Rapid Recommendations practice is typically to use a single drug. Current practice represent a collaborative effort http://www.bmj.com/ between the MAGIC group (http:// The recommendations in this clinical practice guide- Single antiplatelet therapy with aspirin or clopidogrel magicproject.org/) and The line are based on a linked systematic review1 triggered by is an effective intervention for both short and long term BMJ. A summary is offered here a randomised controlled trial published in the New Eng- secondary prevention of stroke and transient ischaemic and the full version including 2 decision aids is on the MAGICapp land Journal of Medicine in August 2018. This trial and attack after an index event. Clinicians sometimes use (https://app.magicapp.org), for all the linked review found that dual antiplatelet therapy alternatives of cilostazole or a combination of dipyrida- devices in multilayered formats. (DAPT) with clopidogrel and aspirin (acetylsalicylic acid) mole and aspirin, both referred to for this recommenda- Those reading and using these 6-9 recommendations should consider during the first 21 days after the index event reduced the tion as single agent therapy. individual patient circumstances, risk of recurrent major ischaemic events compared with Aspirin and clopidogrel have synergistic action to on 23 September 2021 by guest. Protected copyright. and their values and preferences aspirin monotherapy. inhibit platelet aggregation. So it is plausible that the two and may want to use consultation decision aids in MAGICapp to This Rapid Recommendation aims to quickly and facilitate shared decision making transparently translate evidence for working clinicians Box 1 | Linked articles in this BMJ Rapid Recommendations with patients. We encourage cluster adaptation and contextualisation of our recommendations to local or WHAT YOU NEED TO KNOW • Prasad K, Siemieniuk R, Hao Q, et al. Dual antiplatelet other contexts. Those considering People with high risk transient ischaemic therapy with aspirin and clopidogrel for acute high risk use or adaptation of content may • transient ischaemic attack and minor ischaemic stroke: attack or minor ischaemic stroke are at an go to MAGICapp to link or extract a clinical practice guideline. BMJ 2018;363:j656:k5130. its content or contact The BMJ for increased risk of recurrent stroke and death doi:10.1136/bmj.k5130 permission to reuse content in this Aspirin and clopidogrel decrease this risk, article. • – Summary of the results from the Rapid even more so when used in combination Recommendation process • We make a strong recommendation for dual • Hao Q, Tampi M, O’Donnell M, Foroutan F, Siemieniuk RAC, antiplatelet therapy (DAPT) with clopidogrel Guyatt G. Clopidogrel plus aspirin versus aspirin alone and aspirin to be started within 24 hours in for acute minor ischaemic stroke or high risk transient patients who have had a high risk transient ischaemic attack: systematic review and meta-analysis. ischaemic attack or minor stroke BMJ 2018;363:k5108. doi:10.1136/bmj.k5108 We make a strong recommendation for DAPT – Review of all available randomised trials that assessed • dual antiplatelet therapy (clopidogrel and aspirin) to be continued for 10-21 days, at which versus aspirin monotherapy after a high risk transient point patients should continue with single ischaemic attack or minor stroke antiplatelet therapy • MAGICapp (www.magicapp.org) • DAPT is not to be used for major stroke – Expanded version of the results with multilayered because of the increased risk of intracranial recommendations, evidence summaries, and decision bleeding in these patients aids for use on all devices No commercial reuse: See rights and reprints http://www.bmj.com/permissions 1 of 10 RAPID RECOMMENDATIONS BMJ: first published as 10.1136/bmj.k5130 on 18 December 2018. Downloaded from Recommendation 1: Dual vs single antiplatelet therapy Population Patients that have experienced: High risk Minor ischaemic transient ischaemic or stroke attack (TIA) A score of 4 or more on the ABCD2 scale, A score of 3 or less on the National Institutes of which estimates the risk of recurrent Health Stroke Scale (NIHSS), and no persistent stroke aer a TIA disabling neurological decit 07042 Interventions compared Dual antiplatelet Single agent therapy ASA therapy Aspirin and + or All identied trials ASA http://www.bmj.com/ clopidogrel CLOP compared with aspirin alone Recommendation on 23 September 2021 by guest. Protected copyright. Strong Weak Weak Strong We recommend dual antiplatelet therapy over single agent therapy. Start as soon as possible aer index event. Comparison of benets and harms Favours dual antiplatelets No important difference Favours single agent Within 90 days Events per 1000 people Evidence quality Non-fatal recurrent stroke 44 19 fewer 63 High All cause mortality 6 No important difference 5 Moderate Functional disability 128 14 fewer 142 Moderate Poor quality of life 55 13 fewer 68 Moderate Recurrent TIA 36 No important difference 40 Moderate Moderate or major bleeding 5 2 fewer 3 Moderate Minor bleeding 13 7 fewer 6 High No commercial reuse: See rights and reprints http://www.bmj.com/permissions 2 of 10 RAPID RECOMMENDATIONS BMJ: first published as 10.1136/bmj.k5130 on 18 December 2018. Downloaded from Recommendation 1: Dual vs single antiplatelet therapy (continued) Key practical issues Dual antiplatelets Single agent Two different tablets taken once daily at same time A single aspirin tablet once daily Aspirin tablet should be swallowed whole, but clopidogrel tablet can be crushed or split Dosing Values and preferences Although dosing varied slightly in the included trials, for The panel believes almost all patients place a high value on clopidogrel, most physicians and patients would probably avoiding a recurrent stroke and a lower value on avoiding prefer a loading dose of 300 mg rather than a higher moderate or major bleeding. dose. For aspirin, a daily dose between 75 mg and 81 mg represents a reasonable choice. http://www.bmj.com/ on 23 September 2021 by guest. Protected copyright. No commercial reuse: See rights and reprints http://www.bmj.com/permissions 3 of 10 RAPID RECOMMENDATIONS BMJ: first published as 10.1136/bmj.k5130 on 18 December 2018. Downloaded from Recommendation 2: Duration of dual antiplatelet therapy Population ASA + CLOP Patients initiating dual antiplatelet therapy aer TIA or minor ischaemic stroke Interventions compared Shorter duration Longer duration Dual antiplatelet therapy or Dual antiplatelet therapy for 10-21 days aer TIA for 22-90 days aer TIA or minor stroke or minor stroke Recommendation Strong Weak Weak Strong We recommend administering dual antiplatelet therapy for 10-21 days aer the index event http://www.bmj.com/ Comparison of benets and harms Favours 10-21 days No important difference Favours 22-90 days Within 90 days Events per 1000 people Evidence quality on 23 September 2021 by guest. Protected copyright. Ischaemic stroke 10 No important difference 14 Moderate Moderate or major bleeding 3 3 fewer 6 High Key practical issues All people taking dual antiplatelets Most patients should probably remain on single antiplatelet therapy indenitely Switch to anticoagulation instead of antiplatelet therapy when stroke workup reveals an indication (such as atrial brillation or patent foramen ovale without plans for closure) Disclaimer: This infographic is not a clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its
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