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The Extended Window for Dual Antiplatelet Therapy: A Closer Look at Its Efficacy and Risks

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Anthony Raphael
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The Extended Window for Dual Antiplatelet Therapy: A Closer Look at Its Efficacy and Risks

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In the field of stroke prevention, dual antiplatelet therapy (DAPT) has been a significant point of focus. A recent study led by Yilong Wang, MD, PhD, published in the New England Journal of Medicine, suggests extending the time window for dual antiplatelet therapy to 72 hours. This research, supported by the National Natural Science Foundation of China and the National Key R&D Program of China, presents a novel perspective on the timing of administering DAPT. However, it also emphasizes the need for caution in patients with a history of cerebral or systemic hemorrhage due to increased bleeding risks.

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Study Outline and Findings

The study was conducted in China involving patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) who hadn't undergone thrombolysis or thrombectomy. Participants were randomly assigned to receive clopidogrel plus aspirin or aspirin alone within 72 hours after symptom onset. The research found that the combined clopidogrel aspirin therapy initiated within 72 hours after stroke onset led to a lower risk of new stroke at 90 days than aspirin therapy alone. However, it also highlighted a higher risk of moderate to severe bleeding.

The INSPIRES Trial

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Similarly, the INSPIRES trial found that DAPT benefits patients with minor ischemic stroke or high-risk TIA even when administered within 72 hours after onset. The combination of clopidogrel plus aspirin resulted in a decrease in new stroke within 90 days compared to aspirin alone. The trial expanded the pool of patients receiving DAPT and indicated evidence to support expanding the time window for DAPT to 72 hours. However, the results also highlighted the need to balance early benefit and bleeding risk, emphasizing that long-term use of clopidogrel-aspirin is not recommended.

Interpreting the Results

The study involving 3,050 patients in each group found that 7.3% of patients in the clopidogrel-aspirin group and 9.2% in the aspirin group had a new stroke at 90 days. Moderate-to-severe bleeding occurred more frequently in the clopidogrel-aspirin group. This study provides evidence to support expanding the time window for DAPT to 72 hours. However, the timing should be interpreted as 'as soon as possible, but within 72 hours', necessitating a loading dose of clopidogrel, since its omission would be akin to delaying treatment.

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The Importance of Urgent Evaluation and Treatment

The risk of recurrent stroke occurs early, underscoring the importance of urgent evaluation and treatment for transient ischemic attack (TIA) and minor stroke. The efficacy of short-term dual antiplatelet therapy with clopidogrel–aspirin or ticagrelor–aspirin if initiated within 24 hours has been previously mentioned. The recent study posits that this window could be extended to 72 hours, presenting a wider opportunity for effective intervention.

Conclusion

While the extended time window for DAPT shows promising results in terms of reducing the risk of new stroke, the associated increased risk of bleeding cannot be overlooked. The balance between these two factors is crucial, and DAPT must be administered judiciously. Only a careful, individualized approach to each patient, considering their specific circumstances and risks, will ensure the most effective and safest treatment plan. As research continues, the development of more targeted antithrombotic agents in the future could further refine this balance.

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