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Switching From Aspirin Monotherapy After Noncardioembolic Stroke: A Systematic Review and Network Meta-Analysis
Aaron Rothstein1, Ossama Khazaal1, Steven Messe1
1Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (A.R., O.K., S.R.M., S.E.K.).
Stroke
|December 5, 2025
Summary
For patients experiencing ischemic stroke on aspirin, switching to alternative antithrombotic therapy did not conclusively reduce recurrent stroke or cardiovascular events. Further trials are needed to identify optimal secondary prevention strategies for this high-risk group.
Area of Science:
- Neurology
- Cardiology
- Pharmacology
Background:
- Ischemic stroke patients on aspirin face secondary prevention dilemmas.
- Switching antithrombotic therapy effectiveness is uncertain.
Purpose of the Study:
- To systematically review and compare antithrombotic therapies for secondary stroke prevention.
- Evaluate alternatives to aspirin for patients with ischemic stroke.
Main Methods:
- Systematic review and network meta-analysis of randomized controlled trials.
- Included 9 studies (N=5459) comparing aspirin continuation vs. alternatives.
- Primary outcome: recurrent ischemic stroke; Secondary outcome: composite vascular events.
Main Results:
- Switching therapy showed a pooled relative risk of 0.88 (CI 0.76-1.03) for recurrent stroke.
- Composite outcome showed a pooled relative risk of 0.89 (CI 0.72-1.10).
- Dabigatran, apixaban, and aspirin+rivaroxaban ranked highest but were not significantly better than aspirin.
Conclusions:
- Switching antithrombotic therapy after ischemic stroke on aspirin lacks conclusive benefit.
- No alternative therapy demonstrated significant superiority over continued aspirin.
- Further research is required to optimize secondary prevention in this population.
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