Episode 346: 245. Duration of benefit and risk of dual antiplatelet therapy after mild ischemic stroke

And now a secondary analysis of the trial focused on the timing of major ischemic events and the potential tradeoffs of benefits and risks,------ maybe there is magic sauce where the benefit is drastically greater than risk and vice versa!

Guan L et al. Duration of benefit and risk of dual antiplatelet therapy up to 72 hours after mild ischemic stroke and transient ischemic attack. Neurology 2024 Oct 8; 103:e209845. (https://doi.org/10.1212/WNL.0000000000209845)

The goal is less ischemic events with the DAPT but there is a risk of more bleeding and maybe if we tease out the data we can find the exact right time—not too much, not too little but just right.

They found the benefit of decrease ischemic stroke

was front-loaded, with roughly a 1.5% absolute risk reduction (ARR) for major ischemic events in the first week, a 0.5% ARR in the second week, and a nonsignificant 0.29% ARR in the third week.

The bleeding risk was constant right around ARR 0.1%

Thus three weeks remains reasonable to rec DAPT—remember at three weeks the decrease ischemic event rate in absolute terms was 0.3 and the bleeding risk was around 0.1……. the real magic does appear to be in the first week when the risk of repeart event is around 1.5%