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Antiplatelet Regimen for Patients With Breakthrough Strokes While on Aspirin: A Systematic Review and Meta-Analysis
Meng Lee1, Jeffrey L Saver1, Keun-Sik Hong1
1From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan (M.L., Y.-L.W.); Stroke Center, University of California, Los Angeles (J.L.S., N.M.R.); Department of Neurology, Ilsan Paik Hospital, Inje University, Gimhae, South Korea (K.-S.H.); and Department of Neurology, Medical University of South Carolina, Charleston (B.O.).
Insights
Adding or switching antiplatelet therapy beyond aspirin for patients with ischemic stroke or transient ischemic attack significantly reduces risks of future vascular events and recurrent stroke. Early initiation of these strategies offers more consistent benefits.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Uncertainty exists regarding optimal antiplatelet therapy for patients experiencing ischemic stroke or transient ischemic attack while already on aspirin.
- Aspirin monotherapy is a common treatment, but its efficacy in preventing recurrent events in this specific patient population requires further investigation.
Purpose of the Study:
- To systematically review and meta-analyze evidence on the effectiveness of alternative antiplatelet strategies compared to aspirin monotherapy.
- To evaluate the impact of adding or switching to other antiplatelet agents on major adverse cardiovascular events and recurrent stroke.
Main Methods:
- Systematic search of PubMed and bibliographies for randomized trials and cohort studies published between 1966 and August 2016.
- Inclusion criteria: patients on aspirin at the time of an index ischemic stroke or transient ischemic attack.
- Meta-analysis using a random effects model to combine hazard ratios for major adverse cardiovascular events and recurrent stroke.
Main Results:
- Five studies involving 8723 patients were analyzed, with clopidogrel and ticagrelor being the alternative agents studied.
- Addition or switch to another antiplatelet agent significantly reduced the risk of major adverse cardiovascular events (HR, 0.68; 95% CI, 0.54-0.85) and recurrent stroke (HR, 0.70; 95% CI, 0.54-0.92) compared to aspirin monotherapy.
- Early initiation of alternative antiplatelet regimens (within days of the index event) demonstrated more homogenous evidence of benefit.
Conclusions:
- For patients experiencing ischemic stroke or transient ischemic attack while on aspirin, adding or switching to another antiplatelet agent is associated with reduced future vascular events.
- Early implementation of these alternative antiplatelet strategies, particularly in the initial days post-event, is recommended for enhanced efficacy.
- These findings support a shift towards more aggressive antiplatelet therapy in select high-risk patients to prevent secondary events.
Background And Purpose:
Optimal antiplatelet therapy after an ischemic stroke or transient ischemic attack while on aspirin is uncertain. We, therefore, conducted a systematic review and meta-analysis.
Methods:
We searched PubMed (1966 to August 2016) and bibliographies of relevant published original studies to identify randomized trials and cohort studies reporting patients who were on aspirin at the time of an index ischemic stroke or transient ischemic attack and reported hazard ratio for major adverse cardiovascular events or recurrent stroke associated with a switch to or addition of another antiplatelet agent versus maintaining aspirin monotherapy. Estimates were combined using a random effects model.
Results:
Five studies with 8723 patients with ischemic stroke or transient ischemic attack were identified. Clopidogrel was used in 4 cohorts, and ticagrelor was used in 1 cohort. Pooling results showed that addition of or a switch to another antiplatelet agent, versus aspirin monotherapy, was associated with reduced risks of major adverse cardiovascular events (hazard ratio, 0.68; 95% confidence interval, 0.54-0.85) and recurrent stroke (hazard ratio, 0.70; 95% confidence interval, 0.54-0.92). Each of the strategies of addition of and switching another antiplatelet agent showed benefit versus continued aspirin monotherapy, and studies with regimen initiation in the first days after index event showed more homogenous evidence of benefit.
Conclusions:
Among patients who experience an ischemic stroke or transient ischemic attack while on aspirin monotherapy, the addition of or a switch to another antiplatelet agent, especially in the first days after index event, is associated with fewer future vascular events, including stroke.
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