Dual versus mono antiplatelet therapy within 72 hours after onset for mild ischaemic stroke or transient ischaemic attack: meta-analysis of randomised controlled trials.

Background: Although previous evidence generally agreed on the short-term dual antiplatelet therapy (DAPT) for mild stroke or transient ischaemic attack (TIA), there is no consensus on the optimal threshold for stroke severity and initiation timing of DAPT. We conducted an updated meta-analysis of randomised controlled trials to evaluate early DAPT versus single therapy in mild stroke or TIA.

Methods: We systematically reviewed double-blind and randomised controlled trials up to October 2024 evaluating DAPT versus monotherapy for acute mild, non-cardioembolic ischaemic stroke (National Institute of Health Stroke Scale; NIHSS≤5) or TIA within 72 hours of ictus. Random effects models generated risk ratio (RR) with 95% CIs for outcomes including stroke, composite vascular events, ischaemic stroke, major bleeding, haemorrhagic stroke and all-cause mortality.

Results: Pooled data from five trials (n=27 559) demonstrated that DAPT versus monotherapy lowered the risk of stroke recurrence (RR, 0.77; 95% CI 0.70 to 0.83), composite vascular events (RR, 0.75; 95% CI 0.68 to 0.83) and ischaemic stroke (RR, 0.74; 95% CI 0.68 to 0.81). However, DAPT increased the risk of major bleeding (RR, 2.19; 95% CI 1.38 to 3.49) and haemorrhagic stroke (RR, 2.08; 95% CI 1.13 to 3.82), with no significant increase in the risk of all-cause mortality (RR, 1.28; 95% CI 0.95 to 1.71).

Conclusions: For acute mild stroke (NIHSS ≤5) or patients with TIA within 72 hours of ictus, early DAPT initiation demonstrates net clinical benefit through reducing ischaemic events, despite an increase in bleeding complications, without affecting mortality.