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INSPIRES

Problem
DAPT after minor stroke/TIA
Format
Multicenter, double-blinded, two-by-two factorial, randomized, placebo-controlled trial.
Treatment
Aspirin + clopidogrel vs aspirin + placebo
Population
6100 patients
Inclusion criteria
Mild ischaemic stroke (NIHSS <6) or high risk TIA (ABCD >3) within 72hrs confirmed by imaging.
Exclusion criteria
  • Specific cardiogenic ischaemic cerebrovascular diseases (e.g. combined with atrial fibrillation, heart valve prosthesis, atrial myxoma, endocarditis, etc.)
     

  • Other ischaemic cerebrovascular diseases with specific causes (e.g. aortic dissection, vasculitis, vascular malformation, etc.)
     

  • Non-cerebral vascular disease (e.g. intracranial tumours, multiple sclerosis)
     

  • Cerebral infarction of large area (infarct size greater than half the single lobe area)
     

  • CT indicating haemorrhagic transformation of cerebral infarction before randomization
     

  • Pre-existing contraindication to clopidogrel, aspirin or statin drugs.

  • MRS > 2 before onset
     

  • Use of intravenous or arterial thrombolysis intravascular therapy or bridge therapy after onset.
     

  • Use of defibrinating therapy e.g. snake venom, defibrase, lumbrokinase, etc., use of anticoagulant therapy e.g argatroban, or use of antiplatelet therapy except clopidogrel and aspirin, such as tirofiban, ticagrelor, ozagrel, etc. after onset.
     

  • Creatine Kinase ≥5 times upper limit of normal value after onset.
     

  • Use of drugs affecting metabolism of statins such as immune-suppressive drugs, antifungal agents, or fibrates drugs within 14 days before randomisation.
     

  • Severe hepatic or renal insufficiency.
     

  • Usage of dual antiplatelet therapy with aspirin plus clopidogrel within 14 days before randomisation. (patients who received dual antiplatelet therapy [aspirin combined with clopidogrel] but did not use clopidogrel with loading dose after onset were excluded).
     

  • Use of Intensive statin therapy within 14 days before randomisation (atorvastatin ≥40mg/d or rosuvastatin ≥ 20mg/d).
     

  • Pre-existing intracranial haemorrhage.
     

  • GI bleeding or major surgery within 90 days before randomisation.
     

  • Pre-existing extracranial angioplasty or vascular surgery.
     

  • Anticipated requirement for long-term non-study antiplatelet drugs, or non-steroid anti-inflammatory drugs.
     

  • Experimental drugs need to stop due to angioplasty or vascular surgery, which was planned or likely to perform within 90 days after randomisation.
     

  • Patients with severe disease expected to live <90 days.
     

  • Pregnant or childbearing-age women who have no effective contraceptives or positive pregnancy test records.
     

  • Patients undergoing experimental drugs or device tests.
     

  • Unable to finish follow-up of 90 days.

Follow-up
1 year
Primary endpoint
Stroke at 90 days
Secondary endpoint(s)
  • Composite vascular events (e.g. stroke, MI, and cardiovascular death).
     
  • Ischaemic stroke
     
  • Transient ischaemic attack
     
  • Myocardial infarction
     
  • Vascular death
     
  • All-cause death
     
  • Poor functional outcome (mRS 2-6)
     
  • Quality of life (EQ-5D scale).
     
  • Safety outcomes with antiplatelets and statins.
Details

Randomized by 2x2 factorial design:

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  1. Intensive antiplatelet therapy + immediate high-intensity statin therapy (80mg atorvastatin)

  2. Intensive antiplatelet therapy + delayed high-intensity statin therapy (40mg atorvastatin)

  3. Standard antiplatelet therapy + immediate high-intensity statin therapy (80mg atorvastatin)

  4. Standard antiplatelet therapy + delayed high-intensity statin therapy (40mg atorvastatin)

Brief summary
Evidence for DAPT for up to 72 hours but with an increased risk of bleeding.

PAPER: Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke

Date
28 December 2023
Journal
NEJM
Information

Benefits:

  • DAPT if giving within 72hrs of minor stroke/TIA reduces stroke recurrence at 90 days compared to aspirin only

  • No significant difference in composite cardiac events from DAPT vs aspirin only

Risks:

  • Risk of adverse bleeding events 2x higher with DAPT vs aspirin only

Reference
Gao Y, Chen W, Pan Y, Jing J, Wang C, Johnston SC, et al. Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke. The New England Journal of Medicine. 2023; 389 (26): 2413-2424. 10.1056/NEJMoa2309137.

Content written by Dr Nikhil Math

An ongoing project between Dr. Wei Jia Zhang, William Law, and the St. George's Hospital Neuro/Stroke Journal Club.

 

Disclaimer: this website is a work in progress. Final website design and content is subject to change.

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Contact:

helloneurotrials@gmail.com

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