Dual Antiplatelet Therapy For High Risk TIA and Minor Stroke BMJ Rapid Recommendation

Practice Guidelines
Dual Antiplatelet Therapy

for High-Risk TIA and Minor Stroke:
BMJ Rapid Recommendation
National Institutes of Health (NIH) Stroke Scale
Key Points for Practice
score of 3 or less. The risk of recurrence after
• A 10- to 21-day course of dual antiplatelet therapy reduces minor stroke is similar to that after a high-risk
stroke recurrence and improves quality of life after mild
stroke or high-risk TIA.
TIA. The NIH Stroke Scale ranges from 0 to 42
and is based on measures of motor and sensory
• Low-dose aspirin and a 300-mg loading dose of clopi-
dogrel should be started as soon as imaging rules out function, language and speech, vision, level of
hemorrhage. consciousness and attention, and neglect. Dual
• After 10 to 21 days of daily low-dose aspirin and clopi- antiplatelet therapy should be started as soon as
dogrel, 75 mg, the patient should be switched to a single brain imaging rules out intracranial hemorrhage.
antiplatelet drug. Although trials used various dosing strategies,
From the AFP Editors members of the BMJ and MAGIC panel recom-
mend a loading dose of 300 mg of clopidogrel fol-
lowed by 75 mg daily, and low-dose aspirin at 75
Dual antiplatelet therapy after stroke has to 81 mg daily. The aspirin should be taken whole
not previously been shown to improve outcomes without food, but clopidogrel can be crushed or
over a single agent. Based on a recent randomized split and taken with or without food.
controlled trial followed by a systematic review, When imaging will be performed more than
the BMJ and MAGIC group concluded that dual 24 hours after symptom onset, treatment should
antiplatelet therapy use for a limited period after be initiated as soon as minor ischemic stroke or
mild stroke is beneficial. The combination of low- transient TIA is diagnosed by a physician with
dose aspirin and clopidogrel (Plavix) reduces intent to image as soon as possible.
recurrent stroke and disability compared with Evidence indicates that there is no improve-
aspirin alone when started as soon as possible ment in stroke-related outcomes and increased
after a high-risk transient ischemic attack (TIA) risk of bleeding with continuation of dual anti-
or minor ischemic stroke without persistent dis- platelet therapy in the long term (22 to 90 days)
abling neurologic deficit and continued for 10 to after stroke. Patients, however, should likely
21 days.
The severity of TIA can be determined using
the ABCD2 score (Table 1). Dual antiplatelet TABLE 1
therapy is recommended for an ABCD2 score of
4 or greater. Minor stroke can be identified by a ABCD2 Score for Transient Ischemic Attack
Criteria Score
Coverage of guidelines from other organizations does not Age 1 point if > 60 years
imply endorsement by AFP or the AAFP.
Blood pressure 1 point if > 140/90 mm Hg
This series is coordinated by Sumi Sexton, MD,
Editor-in-Chief. Clinical signs 1 point if speech disturbance only
A collection of Practice Guidelines published in AFP is avail- 2 points if unilateral weakness
able at https://w ww.aafp.org/afp/practguide.
CME This clinical content conforms to AAFP criteria for Diabetes 1 point if present
continuing medical education (CME). See CME Quiz on mellitus
page 336.
Duration 1 point if 10 to 59 minutes
Author disclosure: No relevant financial affiliations.
2 points if ≥ 1 hour
378 American
Downloaded Family
from the AmericanPhysician
Family Physician website at www.aafp.org/afp. Copyright © 2019 American Academy
www.aafp.org/afp of Family
Volume Physicians.
100, Number 6 For the private,15,
◆ September noncom-
mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.
2019
PRACTICE GUIDELINES
continue to take one agent for the forseeable

future. Dual antiplatelet therapy should not be
used in patients experiencing a major stroke
because of the associated increased risk of intra- Taking Your
Boards This Fall?
cranial bleeding.
Background
The systematic review on which this recommen-
dation was based included three randomized AAFP Family Medicine
controlled trials evaluating dual antiplatelet
therapy compared with aspirin monotherapy in Board Review Self-Study
more than 10,000 patients. These studies identi-
fied that dual therapy decreased nonfatal recur-
Package–13th Edition
rent strokes (number needed to treat [NNT] = 53),
moderate to severe disability (NNT = 72), and • In-depth review of 14 body systems,
poor quality of life (NNT = 77). Dual antiplate- population-based care, and
let therapy had no effect on all-cause mortality
or the incidence of myocardial infarction or
patient-based systems
recurrent TIA, and had some associated harms
of minor (number needed to harm [NNH] = 143) • 175+ case studies
and moderate to major (NNH = 500) extracra-
nial bleeding. • 500+ Board-style questions
The panel believed that most patients would
value preventing another stroke over experienc-
ing bleeding and thus opt for dual therapy over
monotherapy. They also believed most patients
would opt for shorter treatment duration because
of the similar benefits provided, with less associ-
ated harm.
Editor’s Note: The numbers needed to treat

and to harm were calculated by the AFP medical
editors based on raw data provided in the original
BMJ article.
Guideline source: The BMJ and MAGIC Group

Evidence rating system used? Yes
Systematic literature search described? Yes
Guideline developed by participants without
relevant financial ties to industry? Yes
aafp.org/studyyourway
Recommendations based on patient-oriented (800) 274-2237
outcomes? Yes
Published source: BMJ. December 2018;363:k5130
Available at: https://w ww.bmj.com/content/363/bmj.
k5130.long
Lisa Croke
AFP Senior Associate Editor ■
MOC18060976

Dual Antiplatelet Therapy For High Risk TIA and Minor Stroke BMJ Rapid Recommendation

Uploaded by

Copyright:

Available Formats

Dual Antiplatelet Therapy For High Risk TIA and Minor Stroke BMJ Rapid Recommendation

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Dual Antiplatelet Therapy For High Risk TIA and Minor Stroke BMJ Rapid Recommendation

Uploaded by

Copyright:

Available Formats

Practice Guidelines