Excellent outcomes were seen with dual antiplatelet therapy.

Thrombolytic medications have comparable benefits to aspirin for nondisabling mild strokes in terms of recurrent stroke prevention but have increased bleeding risk. Dual antiplatelet therapy (DAPT) has been shown to reduce recurrent stroke risk more than aspirin alone in these patients (N Engl J Med 2013; 369: 11-19).

These authors conducted a randomised noninferiority trial of DAPT with aspirin plus clopidogrel versus alteplase in patients with a mild stroke (NIH stroke scale score five or below with no clear disability) treated at multiple centres in China. DAPT patients received a 300mg loading dose of clopidogrel, followed by 75mg daily for 12 days along with 100mg of aspirin daily for 12 days. Alteplase was given in the standard fashion. Both groups received guideline-based antiplatelet therapy for 90 days. The primary outcome was excellent neurological status at 90 days (modified Rankin scale score zero to one). Safety outcomes included symptomatic intracerebral haemorrhage (sICH) and mortality.

During the 3.5-year study period, 719 patients (mean age, 64 years; 31% women) were enrolled. The median NIH stroke scale score was two, and patients were treated at an average of three hours following symptom onset. The rate of excellent neurological outcome was 93.8% in the DAPT group and 91.4% with alteplase, confirming noninferiority of DAPT. The rate of sICH was low in both groups (0.3% DAPT, 0.9% alteplase). The rate of any bleeding event was lower with DAPT than with alteplase (1.6% vs 5.4%). As expected with a mild-stroke population, mortality at 90 days was low (below 1%) in both groups.

Comment: These data are useful for clinicians because mild strokes are seen frequently in the emergency department. For patients with mild, nondisabling symptoms such as mild dysarthria or ataxia or mild facial weakness, DAPT is a very reasonable treatment, and there is no clear indication for use of thrombolytic medications.

Seemant Chaturvedi, MD, Stewart J. Greenebaum Endowed Professor of Stroke Neurology and Stroke Program Director, University of Maryland Medical System, Baltimore; Vice-Chair for Strategic Operations, Department of Neurology, University of Maryland, Baltimore, USA.

Chen H-S, et al. Dual antiplatelet therapy vs alteplase for patients with minor nondisabling acute ischemic stroke: the ARAMIS randomized clinical trial. JAMA 2023; 329: 2135-2144.

This summary is taken from the following Journal Watch titles: Neurology, Hospital Medicine.