Ticagrelor versus clopidogrel in dual antiplatelet therapy after minor stroke or transient ischemic attack: an updated network meta-analysis

Gabriel Marinheiro; Beatriz Araújo; Gabriel de Almeida Monteiro; Marianna Leite; Antonio Mutarelli; Artur Menegaz de Almeida; Joaquim Francisco Cavalcante-Neto; André Rivera; Agostinho C Pinheiro; João Paulo Mota Telles

doi:10.1007/s00415-024-12330-3

Ticagrelor versus clopidogrel in dual antiplatelet therapy after minor stroke or transient ischemic attack: an updated network meta-analysis

J Neurol. 2024 Apr 5. doi: 10.1007/s00415-024-12330-3. Online ahead of print.

Affiliations

¹ School of Medicine, Federal University of Ceará, Sobral, Brazil. gabrielmarinheirosb@gmail.com.
² Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil.
³ School of Medicine, Federal University of Ceará, Sobral, Brazil.
⁴ School of Medicine, Santa Marcelina College, São Paulo, Brazil.
⁵ School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil.
⁶ Federal University of Mato Grosso, Sinop, Brazil.
⁷ Department of Neurosurgery, Federal University of Ceará, Sobral, Brazil.
⁸ Department of Neurology, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, USA.
⁹ Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, USA.
¹⁰ Department of Neurology, University of São Paulo, São Paulo, Brazil.

^# Contributed equally.

PMID: 38580815
DOI: 10.1007/s00415-024-12330-3

Abstract

Background: Dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin is a well-established practice after a minor stroke or transient ischemic attack (TIA). However, ticagrelor plus aspirin may be an alternative.

Aims: We systematically searched PubMed, Embase, and Cochrane Central from inception to January 2024. We included randomized controlled trials (RCTs) enrolling adults with acute minor stroke or TIA within 72 hours of the onset of the symptoms.

Results: A total of 8 RCTs were included in our meta-analysis. Ticagrelor plus aspirin (RR, 0.70; 95% CrI 0.52, 0.91) and clopidogrel plus aspirin (RR, 0.79; 95% CrI 0.64, 0.98) were superior to aspirin in preventing stroke recurrence in overall analysis. Excluding studies with dual antiplatelet up to 90 days, ticagrelor plus aspirin was the only strategy that maintained superiority compared with aspirin regarding stroke recurrence (RR, 0.70; 95% CrI 0.51, 0.95) and ischemic stroke (RR, 0.68; 95% CrI 0.47, 0.94). There was no significant difference between treatment groups regarding hemorrhagic stroke, functional disability, and mortality.

Conclusions: DAPTs were superior to aspirin in preventing recurrence or ischemic stroke. Although no significant difference was observed between DAPTs, ticagrelor plus aspirin may be related to worse major bleeding results, including intracranial bleeding. Ticagrelor plus aspirin is a considerable option for patients after a minor stroke or TIA.

Keywords: Clopidogrel; Dual antiplatelet; Meta-analysis; Stroke; Ticagrelor; Transient ischemic attack.

Publication types

Review