Optimization and individualization of dual antiplatelet therapy strategies for older patients with mild to moderate ischemic stroke: a meta-analysis

Mahmoud, Abdelrahman1,#; Rezq, Hazem2,*,#; Elfil, Mohamed3; Abdelsayed, Kerollos4,5; Ahmed, Ali Ashraf Salah1; Amin, Ahmed Mazen6; Abdelraouf, Mohamed R.7; Osman, Ahmed S. A1; Abdelazeem, Basel8; Brašić, James Robert9,10,11,*

1Faculty of Medicine, Minia University, Minia, Egypt

2Faculty of Medicine, Al-Azhar University, Cairo, Egypt

3Department of Neurology, University of Miami/Jackson Health System, Miami, FI, USA

4Clinical Research Department, Aswan Heart Centre and Research, Magdi Yacoub Foundation, Aswan, Egypt

5Heart Rhythm Science Center, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA

6Faculty of Medicine, Mansoura University, Mansoura, Egypt

7Faculty of Medicine, Alexandria University, Alexandria, Egypt

8Department of Cardiology, School of Medicine, West Virginia University, Morgantown, WV, USA

9Department of Psychiatry, New York City Health and Hospitals/Bellevue, New York, NY, USA

10Department of Psychiatry, New York University Grossman School of Medicine, New York University Langone Health, New York, NY, USA

11Section of High-Resolution Brain Positron Emission Tomography Imaging, Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

*Correspondence to: Hazem Rezq, MBBCh, hazemsalah2047@gmail.com; James Robert Brašić, MD, James.Brasic@nyulangone.org.

Abstract

Although many interventions have been proposed to reduce morbidity and mortality following a transient ischemic attack or ischemic stroke, the optimal procedure is controversial. Since dual antiplatelet therapy with clopidogrel and aspirin and aspirin alone are widely used for people who have experienced a transient ischemic attack or an ischemic stroke, we sought to identify the benefits and risks of each intervention to provide healthcare provider with objective evidence for use in construct comprehensive treatment plans. We conducted a systematic review and meta-analysis to assess dual antiplatelet therapy vs. monotherapy for stroke prevention after mild to moderate ischemic strokes utilizing randomized controlled trials from PubMed, EMBASE, Web of Science, SCOPUS, and Cochrane up to April 3, 2024, and mean difference for continuous outcomes and risk ratio (RR) for dichotomous outcomes, with 95% confidence intervals (CI). Seven randomized controlled trials with 20,992 patients were included. Dual antiplatelet therapy reduced combined ischemic and hemorrhagic stroke recurrence (RR = 0.77, 95% CI: 0.70, 0.84, P < 0.00001), ischemic strokes (RR = 0.74, 95% CI: 0.67, 0.82, P < 0.00001), poor functional outcome (RR = 0.89, 95% CI: 0.81, 0.98, P = 0.02), and early neurologic deterioration (RR = 0.46, 95% CI: 0.24, 0.88, P = 0.04), but increased bleeding events (RR = 1.74, 95% CI: 1.23, 2.48, P = 0.002). Both groups were comparable in hemorrhagic strokes, all-cause mortality, transient ischemic attack, and myocardial infarction. Taken together, dual antiplatelet therapy improves stroke prevention and functional outcomes but requires caution due to increased bleeding risk.

轻度至中度缺血性脑卒中老年患者双重抗血小板治疗策略的优化和个体化：meta分析

摘要

尽管已提出了许多干预措施来降低短暂性脑缺血发作或缺血性脑卒中后的发病率和死亡率，但最佳治疗方法仍存在争议。由于氯吡格雷和阿司匹林的双重抗血小板疗法以及单用阿司匹林被广泛用于治疗短暂性脑缺血发作或缺血性脑卒中患者，此META分析试图确定每种干预措施的益处和风险，以便为医疗服务提供者提供客观证据，从而制定全面的治疗计划。利用截至 2024 年 4 月 3 日的 PubMed，EMBASE，Web of Science、SCOPUS 和 Cochrane 中的随机对照试验进行了系统综述和荟萃分析，评估了轻度至中度缺血性脑卒中后预防脑卒中的双联抗血小板疗法与单药疗法的比较，连续性结果的平均差 (MD) 和二分法结果的风险比 (RR) 以及 95% 的置信区间 (CI)。纳入了 7 项随机对照试验，共 20,992 例患者。双联抗血小板疗法降低了合并缺血性和出血性卒中的复发率（RR = 0.77，95% CI：0.70，0.84，P < 0.00001）、缺血性卒中复发率（RR = 0.74，95% CI：0. 67, 0.82, P < 0.00001）、功能预后差的发生（RR = 0.89, 95% CI: 0.81, 0.98, P = 0.02）和早期神经功能恶化（RR= 0.46, 95% CI: 0.24, 0.88, P = 0.04），但出血事件增加（RR = 1.74, 95% CI: 1.23, 2.48, P = 0.002）。在出血性脑卒中、全因死亡率、短暂性脑缺血发作和心肌梗死方面，两组患者具有可比性。综上所述，双联抗血小板疗法可改善脑卒中预防和功能预后，但由于出血风险增加，需谨慎使用。