• Muhammad Basil Raza, Ali Akhtar, and Maham Khan.
• General Medicine, Kings College NHS Foundation Trust, United Kingdom.
• Singapore Med J. 2025 Jan 3.

IntroductionWe explored the efficacy and safety of dual antiplatelet therapy (DAPT) for individuals diagnosed with stroke or transient ischaemic attack (TIA), incorporating the latest insights from randomised controlled trials (RCTs). The emerging evidence surrounding DAPT in stroke and TIA plays a pivotal role in guiding clinical decisions.MethodsOur study included five RCTs (INSPIRES, THALES, POINT, CHANCE, FASTER) on DAPT (aspirin + P2Y12 inhibitor) initiated within 72 hours of acute stroke or TIA, which evaluated DAPT efficacy and safety over 21-90 days, focusing on new strokes and major bleeding. Secondary outcomes included cardiovascular events and recurrent strokes. Pooled odds ratios (OR) were computed using a random effects model.ResultsThe five RCTs involved 27,559 patients. Our analysis showed that DAPT significantly reduced stroke recurrence (OR 0.75; 95% confidence interval [CI] 0.68-0.82; P <0.001, I2 = 0%) but increased major bleeding risk (OR 2.20; 95% CI 1.38-3.51, P = 0.0009, I2 = 30%). It lowered major adverse cardiovascular events (OR 0.76; 95% CI 0.67-0.85, P < 0.001, I2 = 5%) and recurrent ischaemic events (OR 0.73; 95% CI 0.66-0.80, P < 0.001, I2 = 0%), but raised haemorrhagic stroke risk (OR 2.09; 95% CI 1.14-3.84, P = 0.02, I2 = 8%).ConclusionDual antiplatelet therapy - a combination of aspirin with either ticagrelor or clopidogrel - initated within 72 hours of a high-risk TIA or mild moderate ischaemic stroke is superior to aspirin alone in reducing the risk of recurrent stroke. However, DAPT comes with a higher risk of major bleeding.Copyright © 2025 Singapore Medical Journal.

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