Editors' ChoiceStroke

Decreasing the CHANCE of Stroke

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Science Translational Medicine  24 Jul 2013:
Vol. 5, Issue 195, pp. 195ec120
DOI: 10.1126/scitranslmed.3006976

Transient ischemic attacks (TIAs) are often referred to as “mini-strokes.” They were once thought of as “near miss” events, but it has become clear that there is nothing small about the significance or impact of TIAs. After a TIA, the risk of a full-blown stroke is high, with ~10 to 20% of patients having a stroke within 3 months after the index event, and most within the first 2 days. The role of antiplatelet therapy for preventing additional strokes in patients who have already suffered a first event is well established. However, it is unclear whether dual antiplatelet therapy is beneficial in the setting of TIA or minor stroke (NIH stroke scale score of 3 or less; scores range from 0 to 42, with higher scores signifying greater deficits).

The Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) study by Wang et al. addresses this question. In a randomized, double-blind, placebo-controlled study conducted at 114 centers in China, the investigators randomly assigned 5170 patients within 24 hours of a minor ischemic stroke or high-risk TIA to 3 months of combination therapy with clopidogrel and aspirin, or to treatment with aspirin plus placebo. The primary outcome—stroke within 90 days—was assessed with a Cox proportional-hazards model in an intention-to-treat analysis. The authors found an 8.2% stroke rate in the clopidogrel–aspirin group, compared with an 11.7% rate in the aspirin–placebo group (hazard ratio, 0.68; 95% confidence interval, 0.57 to 0.81; P < 0.001). The incidence of hemorrhagic stroke was 0.3% in each group.

Despite fears of hemorrhagic complications with the use of dual antiplatelet therapy, this study demonstrates that the combination of clopidogrel and aspirin decreases the risk of stroke and does not increase the risk of complications when compared with aspirin alone after a TIA or minor stroke. A limitation of this investigation is the generalizability of results to countries aside from China, where stroke subtypes and prescribed methods for secondary prevention may differ somewhat from those presented in the study. Nevertheless, these results suggest that it is time to recognize that “more is more” in the medical management of TIAs and that an aggressive treatment approach is warranted in the setting of what was once thought to be a “near miss” event.

Y. Wang et al., Clopidogrel with aspirin in acute minor stroke or transient ischemic attack. N. Engl. J. Med. 369, 11–19 (2013). [Abstract]

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