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The INSPIRES Trial: A New Perspective on Dual Antiplatelet Therapy for Minor Ischemic Stroke

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Dr. Jessica Nelson
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The INSPIRES Trial: A New Perspective on Dual Antiplatelet Therapy for Minor Ischemic Stroke

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Overview of the INSPIRES Trial

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The INSPIRES trial, a double-blind placebo-controlled study, was conducted across 222 hospitals in China. The study involved patients diagnosed with minor ischemic stroke or high-risk transient ischemic attack (TIA) of presumed atherosclerotic cause. The primary objective of the trial was to compare the effects of dual antiplatelet therapy (DAPT) – a combination of clopidogrel plus aspirin – with that of aspirin alone. The therapy was administered within a 72-hour window from the onset of acute cerebral ischemia. The primary efficacy and safety outcomes were the incidence of new strokes and moderate to severe bleeding, respectively, both assessed within 90 days.

The Findings of the Trial

The findings of the INSPIRES trial suggest that initiating DAPT within 72 hours after stroke onset led to a lower risk of new stroke at 90 days than treatment with aspirin alone. However, this combined therapy was associated with a low but increased risk of moderate to severe bleeding. This evidence suggests that the benefits of reducing new stroke occurrences could potentially outweigh the risks associated with increased bleeding.

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Implications of the Findings

The results of the INSPIRES trial potentially broaden the time window for the initiation of DAPT. The study's findings may support the expansion of the time window for DAPT to 72 hours, providing evidence for a class Ia recommendation for a 21-day course of aspirin plus clopidogrel starting within 24 hours for patients with noncardioembolic ischemic stroke and National Institutes of Health Stroke Scale (NIHSS) scores of 3 or less.

Underutilization of DAPT in Practice

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Despite these promising results, the underutilization of DAPT in real-world practice has been noted. Just over 40% of stroke patients with an NIHSS score of 3 or less are prescribed DAPT following a minor stroke or TIA. This suggests that further efforts are required to integrate the trial's findings into clinical practice and improve the utilization of DAPT.

Considerations and Limitations

While the trial's results suggest a potential expansion of indications for DAPT, the balance of benefits and risks must be considered. The trial's findings are based on a specifically selected cohort, limiting generalizability. Thus, further research is necessary to confirm these findings across a broader patient population. Additionally, the potential risks associated with increased bleeding due to DAPT need to be carefully considered.

Conclusion

The INSPIRES trial offers new insights into the potential benefits of DAPT for individuals with a minor ischemic stroke or high-risk TIA. It highlights the possibility of extending the time window for treatment initiation, thus potentially improving stroke outcomes. However, the increase in moderate-to-severe bleeding underscores the need for careful patient selection and close monitoring during treatment. As we continue to strive for improved stroke care, these findings add to our growing understanding of the balance between efficacy and safety in stroke treatment strategies.

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