Dual Antiplatelet Therapy in Ischemic Stroke Prevention

Dual antiplatelet therapy (DAPT) has emerged as a critical strategy for reducing early recurrence of ischaemic stroke and transient ischaemic attack (TIA). By combining agents that target distinct pathways of platelet activation, DAPT optimises inhibition of thrombus formation in the acute and subacute phases following minor stroke or high-risk TIA. The most extensively studied regimen pairs aspirin with a P2Y₁₂ receptor antagonist, typically clopidogrel or ticagrelor, for a defined short term (commonly 21–30 days) before de-escalating to monotherapy to balance efficacy with bleeding risk. Mechanistic studies have elucidated synergistic blockade of cyclooxygenase-mediated and ADP-mediated platelet aggregation, while pharmacodynamic assays confirm enhanced platelet inhibition with dual regimens. Clinically, randomised trials demonstrate that DAPT confers a 20–30 per cent relative risk reduction in recurrent ischaemic events during the period of dual coverage, with the greatest absolute benefit observed in patients with non-cardioembolic, minor stroke or high-risk TIA. However, this benefit must be weighed against a two- to three-fold increase in moderate haemorrhagic complications when dual agents are used beyond the acute window. Ongoing research seeks to refine the optimal duration and agent selection, guided by biomarkers of platelet reactivity and individual patient risk profiles, and to explore alternative combinations such as aspirin with phosphodiesterase inhibitors in selected populations. The global significance of DAPT is underscored by its incorporation into international guidelines, highlighting its practical application in reducing the burden of early stroke recurrence and associated disability worldwide.

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Dual Antiplatelet Therapy in Ischemic Stroke Prevention publication trend

The graph below shows the total number of articles in dual antiplatelet therapy in ischemic stroke prevention across all publications each year (not limited to Nature Index journals).

Technical terms

Dual antiplatelet therapy (DAPT): concurrent use of two antiplatelet agents to inhibit platelet aggregation and reduce thrombus formation.

Transient ischaemic attack (TIA): transient focal neurological deficit resolving within 24 hours without imaging evidence of infarction.

P2Y₁₂ receptor antagonist: class of antiplatelet drugs that block ADP-mediated platelet activation (e.g. clopidogrel, ticagrelor).

Modified Rankin Scale (mRS): ordinal scale measuring functional disability or dependence after stroke.

Non-cardioembolic stroke: ischaemic stroke not caused by a cardiac source of embolism.

References

1. European Stroke Organisation expedited recommendation for the use of short-term dual antiplatelet therapy early after minor stroke and high-risk TIA. European Stroke Journal (2021).
2. Antiplatelet Use in Ischemic Stroke. Annals of Pharmacotherapy (2022).
3. Acute Aspirin Plus Cilostazol Dual Therapy for Noncardioembolic Stroke Patients Within 48 Hours of Symptom Onset. Journal of the American Heart Association (2019).
4. Cilostazol improves endothelial function in acute cerebral ischemia patients: a double-blind placebo controlled trial with flow-mediated dilation technique. BMC Neurology (2017).