New Stroke Therapy: A Balancing Act Between Reduced Risk and Increased Bleeding

A novel approach to stroke treatment has recently been proposed, showing promise in reducing the risk of recurrent stroke. According to new research, this therapy has demonstrated a 21% reduction in the likelihood of a subsequent stroke within 90 days, compared to traditional aspirin therapy. However, this new treatment is not without its downsides, as it also carries an increased risk of bleeding, doubling the risk from 0.4% to 0.9%. Therefore, the decision to opt for this therapy involves careful consideration, weighing the benefits of reduced stroke risk against the risks of increased bleeding.

Dual Antiplatelet Therapy: A Promising Contender

The new therapy in question is dual antiplatelet therapy (DAPT) with clopidogrel and aspirin. It has shown significant efficacy if initiated within 24 hours of a transient ischemic attack (TIA) or minor stroke. These conditions require urgent evaluation and treatment, given that the risk of recurrent stroke is high and occurs early. The INSPIRES trial, for instance, showed that DAPT reduced the risk of new strokes within 90 days compared to aspirin alone, even when administered within 72 hours after the onset of mild ischemic stroke or high-risk TIA.

Understanding the Risks and Benefits

However, the use of DAPT also comes with an associated risk. There was a doubling in moderate to severe bleeding with the dual regimen compared to aspirin alone. The American Heart Association updated its guidelines in 2019 to recommend a 21-day course of aspirin plus clopidogrel for patients with noncardioembolic ischemic stroke and NIHSS scores of 3 or less. Despite the notable benefits, DAPT appears to be underutilized in practice, with only just over 40% of stroke patients with an NIHSS score of 3 or less being prescribed DAPT after a minor stroke or transient ischemic attack.

Findings from the INSPIRES Trial

The INSPIRES trial involved 6,100 people with mild ischemic stroke or high-risk TIA. The results showed that DAPT prevented recurrent strokes mainly in people randomized between 48 hours and 72 hours, with a higher risk of bleeding in the clopidogrel-aspirin group. Therefore, it is crucial to time the initiation of DAPT optimally to maximize its benefits while minimizing its risks.

Stroke Prevention: Current Failures and Future Directions

Atrial fibrillation patients currently face significant challenges in stroke prevention. Oral anticoagulants, while reducing the risk of ischemic events, increase the risk of major and clinically relevant hemorrhages and require strict compliance for efficacy. Nonpharmacological methods, such as left atrial appendage closure, have been proposed to prevent ischemic strokes without the need for lifelong anticoagulant use. The Food and Drug Administration (FDA) has approved several approaches, and phase 3 randomized controlled trials are underway to develop more effective stroke prevention strategies.

Final Thoughts

The potential of DAPT as a stroke therapy is clear. However, the decision to opt for this treatment involves a delicate balance between its benefits and risks. Healthcare providers and patients must discuss these factors carefully and make an informed decision. As stroke prevention research continues to evolve, it is hoped that more effective and safer treatments will become available to patients.