Dual antiplatelet therapy with either clopidogrel or ticagrelor is more effective than aspirin alone in preventing recurrent stroke

Reference

Lun R, Dhaliwal S, Zitikyte G, Roy DC, Hutton B, Dowlatshahi D. Comparison of ticagrelor vs clopidogrel in addition to aspirin in patients with minor ischemic stroke and transient ischemic attack: a network meta-analysis. JAMA Neurol 2022;79(2):141-148.

Synopsis

These authors searched MEDLINE, Embase, the Cochrane Registry of Clinical Trials, and the last 20 years of abstracts from international stroke conferences to identify randomized trials that included persons with minor stroke or transient ischemic attacks who were randomized into one of the following comparison groups: ticagrelor and aspirin vs aspirin; clopidogrel and aspirin vs aspirin; or ticagrelor and aspirin vs clopidogrel and aspirin. The inclusion criteria also included at least 30 days of follow-up and an assessment of recurrent stroke and death. They authors included 9 studies (N = 22,098) with 4 subgroup analyses, and all were at low risk of bias. The treatment duration ranged from 21 days to 90 days. The authors pooled the study data and conducted a network meta-analysis. Compared with aspirin monotherapy, the primary outcome (a composite of recurrent ischemic stroke or death within 90 days of enrollment) was less frequent in both dual therapy groups (clopidogrel + aspirin [hazard ratio (HR) 0.74; 95% credible interval (CrI) 0.65 - 0.84]; ticagrelor + aspirin [HR 0.79; 0.68 - 0.91]). Most of the benefit was in ischemic stroke prevention (HR 0.71; 0.62 - 0.82 and 0.74; 0.64 - 0.86, respectively) as there was no statistically significant difference in 90-day mortality in any of the groups. Additionally, dual therapy with clopidogrel and dual therapy with ticagrelor were each associated with a lower risk of functional disability at 90 days (HR 0.82; 0.74 - 0.91 and 0.85; 0.75 - 0.97, respectively). Although dual therapy was associated with more frequent major hemorrhage, the clopidogrel plus aspirin group had fewer events than the ticagrelor plus aspirin group (HR 1.78; 1.09 - 2.92 and 2.63; 1.51 - 4.82, respectively). The authors do not present the data in a manner that allows for estimation of numbers needed to treat.