New stroke risk down with clopidogrel-aspirin initiated within 72 hours

Combined clopidogrel-aspirin therapy initiated within 72 hours after stroke onset leads to lower risk for new stroke at 90 days among patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) of presumed atherosclerotic cause, according to a study published in the Dec. 28 issue of the New England Journal of Medicine.

Ying Gao, M.D., from Beijing Tiantan Hospital, and colleagues conducted a randomized two-by-two factorial trial involving patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause who had not undergone thrombosis or thrombectomy. Patients were randomly assigned to receive clopidogrel plus aspirin or matching clopidogrel placebo plus aspirin in a 1:1 ratio within 72 hours after symptom onset (3,050 in each group).

The researchers found that 7.3 and 9.2 percent of patients in the clopidogrel-aspirin group and aspirin group, respectively, had a new stroke at 90 days (hazard ratio, 0.79). Moderate-to-severe bleeding occurred in 0.9 and 0.4 percent of patients in the clopidogrel-aspirin and aspirin groups, respectively (hazard ratio, 2.08).

"The current trial provides evidence to support expanding the time window for dual antiplatelet therapy to 72 hours," writes the author of an accompanying editorial. "This timing should nevertheless be interpreted as 'as soon as possible, but within 72 hours' and still necessitates a loading dose of clopidogrel, since its omission would be akin to delaying treatment."

The study was partially funded by Sanofi and Beijing Jialin Pharmaceutical.