This study aimed to compare the safety and efficacy of early dual antiplatelet vs. monotherapy in acute (within 3 days from onset to randomisation) ischaemic stroke or transient ischaemic attack (TIA) using data from completed randomised trials. Because different pairs of antiplatelet agents appear to be superior to single agents, it was hypothesised that the composition of agents would be less important than their number in determining safety and efficacy.

Twelve completed RCTs of of 3766 patients were included in the review. The primary outcome was recurrent stroke (ischaemic, haemorrhagic, unknown; fatal, non-fatal).

In comparison with mono antiplatelet therapy, dual therapy (aspirin+dipyridamole and aspirin+clopidogrel) reduced:

• Stroke recurrence: dual 58 (3.3%) vs. mono 91 (5.0%) [risk ratio, 0.67; 95% CI, 0.49 to 0.93]

• Composite vascular event (stroke, MI, vascular death): dual 74 (4.4%) vs. mono 106 (6%) [0.75; 0.56 to 0.99]

• Combination of stroke, transient ischaemic attack, acute coronary syndrome, and all death: dual 100 (1.7%) vs. mono 136 (9.1%) [0.71; 0.56 to 0.91)

Dual therapy was also associated with a non-significant trend to increase major bleeding: dual 15 (0.9%) vs. mono 6 (0.4%) [2.09; 0.86 to 5.06].

The researchers conclude that dual antiplatelet therapy appears to be safe and effective in reducing stroke recurrence and vascular events in patients with acute ischaemic stroke or TIA as compared with monotherapy. They acknowledge that as there were a relatively small number of outcome events; this study is primarily hypothesis-generating and should not lead to modification of treatment guidelines. The ongoing Platelet-Orientated Inhibition in New TIA and minor ischemic stroke (POINT) trial, which is comparing aspirin and clopidogrel vs. aspirin alone, will provide more data on this issue whilst the Triple Antiplatelets for Reducing Dependency after Ischemic Stroke (TARDIS) trial moves the question on by comparing more intensive antiplatelet therapy (aspirin, clopidogrel and dipyridamole) and guideline-based dual antiplatelet therapy (aspirin and dipyridamole).