clopidogrel alone vs aspirin +clopidogrel to prevent recurrent stroke?

[ketap]

hi,friends...i want to ask..have you ever gave to your patient a combination of both aspirin (80mg) and clopidogrel (75mg) to prevent recurrent stroke in a stroke patient? is it really better than using aspirin 80 mg or clopidogrel 75 mg alone?
and if for instance, that patient then has GI discomfort, which one would you consider to be stopped first?

i found several of my patients got those combination from their cardiologist and another neurologist but i cannot find many literature about this...so i do need to ask about this..


best regards,
thank you

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[Hank Rearden]

There are very few evidence based indications for dual antiplatelet therapy in stroke. One is stroke caused by severe intracranial atherosclerotic disease based on the medical arm of SAMMPRIS (Chimowitz et al. NEJM 2011). Keep in mind that this is only temporary dual antiplatelet therapy for 3 months. The other is in patients who are post-stent. In the carotid stenting arm of CREST (Brott et al. 2010) patients received dual antiplatelet therapy for at least one month. More recently, the CHANCE trial (Wang et al. NEJM 2013) suggested that dual antiplatelet therapy started within the 1st 24hrs after minor stroke and continued for 90 days was better than ASA alone. I don't personally know of any stroke docs that are administering dual antiplatelet based on the CHANCE results, mostly because this was a Chinese study and it is unclear if the results are generalizable. A similar study called POINT is currently ongoing in the US.

 

[typhoonegator]

The CHANCE trial has gotten a bit too much play, in my opinion. I kind of wish it hadn't been published in the NEJM. I'm not saying it's wrong, but it is not a definitive result and external validity is a substantial question.

 

[neglect]

Blood pressure and exercise will trump the anti-plt choice by far. Off the top of my head: CAPRIE showed a NNT of about 120 to prevent a stroke with plavix over aspirin. And never has so little been turned into so much. Plavix plus aspirin causes GIB's and does not save strokes, MATCH. IC stenosis as above: dual anti-plts for 3 months. I think the CHANCE trial nearly settles the issue, but it was Chinese and POINT will likely show the same small difference. Or not. Either way: BP, statin, anti-plt, diet, exercise. And on this last point, my understanding is that SAMMPRIS' medical group did better than anticipated - perhaps because they exercised.