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Updated: Jul 19, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Ticagrelor plus aspirin in patients with minor ischemic stroke and transient ischemic attack: a network meta-analysis
Mingxia Li1, Qianru Yang1, Jiankuan Shi1
1Department of Neurology, Xi'an International Medical Center Hospital, Xitai Road, Gaoxin District, Xi'an City, 710010, Shaanxi Province, China.
Insights
Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is recommended for secondary stroke prevention. This study found DAPT superior to aspirin alone, with no significant difference between ticagrelor and clopidogrel, though Asians may benefit from ticagrelor.
Area of Science:
- Cardiology
- Neurology
- Pharmacology
Background:
- Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel is standard for secondary prevention of minor ischemic stroke or transient ischemic attack (TIA).
- CYP2C19 genetic polymorphisms reduce clopidogrel effectiveness, prompting investigation into alternative agents like ticagrelor, which bypasses this metabolic activation pathway.
- The comparative efficacy and safety of ticagrelor versus clopidogrel in stroke patients remain unclear.
Purpose of the Study:
- To conduct a network meta-analysis comparing the efficacy and safety of ticagrelor, clopidogrel, and aspirin for secondary prevention in minor ischemic stroke and TIA populations.
- To evaluate the effectiveness of different antiplatelet strategies in preventing stroke recurrence.
- To assess the safety profiles, specifically major hemorrhage risk, associated with these antiplatelet regimens.
Main Methods:
- A systematic search of Cochrane Library, ClinicalTrials.gov, and PubMed databases was conducted up to June 19, 2023.
- Included were randomized controlled trials (RCTs) comparing antiplatelet drugs in patients with minor stroke or TIA.
- Multivariate meta-analysis using STATA software was employed for statistical analysis.
Main Results:
- Seven RCTs involving 41,745 participants were analyzed.
- Both DAPT regimens (aspirin/clopidogrel and aspirin/ticagrelor) significantly reduced stroke recurrence compared to aspirin alone.
- No significant difference in efficacy or major hemorrhage risk was observed between aspirin/clopidogrel and aspirin/ticagrelor, although DAPT increased major hemorrhage risk versus aspirin monotherapy. Ticagrelor/aspirin showed benefit in Asian populations without increased bleeding.
Conclusions:
- Dual antiplatelet therapy (DAPT) is more effective than aspirin monotherapy for stroke prevention in minor stroke/TIA patients.
- There is little difference in efficacy and safety between ticagrelor-based and clopidogrel-based DAPT.
- Asian populations, particularly Chinese, may derive greater benefit from DAPT with aspirin and ticagrelor, warranting further head-to-head trials.
Background:
Dual antiplatelet therapy (DAPT) with aspirin and clopidogrel was recommended as the secondary prevention of minor ischemic stroke or transient ischaemic attack (TIA). However, genetic polymorphisms of CYP2C19 had been identified as the major cause of poor responsiveness to clopidogrel. Ticagrelor, unlike clopidogrel, did not depend on metabolic activation, but it remained unclear whether ticagrelor was superior to clopidogrel in ischemic stroke. We performed a network meta-analysis to compare the efficacy and safety of ticagrelor, clopidogrel, and aspirin in the minor ischemic stroke and TIA populations.
Methods:
Databases of Cochrane Library, ClinicalTrials.gov, and PubMed were searched up to June 19, 2023. Randomized controlled trials (RCTs) assessing antiplatelet drugs for minor stroke or TIA were included. Statistical processing was conducted by using multivariate meta-analysis routines of STATA.
Results:
Seven RCTs were included involving 41,745 participants. There was no significant difference between the two DAPTs in preventing stroke recurrence (OR, 1.16; 95% CI, 0.93-1.44), ischemic stroke recurrence (OR, 1.16; 95% CI, 0.93-1.45), and major hemorrhage (OR, 1.22; 95% CI, 0.62,2.39). Compared with aspirin alone, the two DAPT regimen reduced the risk of stroke recurrence (clopidogrel: OR, 0.69; 95% CI, 0.60-0.80, ticagrelor: OR, 0.66; 95% CI, 0.49-0.87) and ischemic stroke recurrence, but increased the incidence of major hemorrhage (clopidogrel: OR, 2.05; 95% CI, 1.22- 3.77; ticagrelor: OR, 2.55; 95% CI, 1.25-4.99). Despite being associated with a higher risk of any bleeding, ticagrelor did not impact the composite of vascular events or mortality. While ticagrelor and aspirin reduced the risk of ischemic stroke recurrence (OR, 0.77; 95% CI, 0.63- 0.92) without increasing the risk of major bleeding (OR 0.94; 95% CI 0.45-1.95) in the Asian population mainly Chinese.
Conclusions:
DAPT was superior to aspirin in stroke prevention, but little difference existed between the two DAPT regimens. Asian population mainly Chinese may benefit from DAPT with aspirin and ticagrelor. But further head-to-head RCTs are needed to validate the study results.
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