Dual antiplatelet therapy after minor, warning stroke: A missed opportunity

Not a lot of individuals, especially women, are initiated on dual antiplatelet therapy (DAPT) with aspirin and clopidogrel after a transient ischaemic attack (TIA) or minor acute ischaemic stroke (AIS), and this is despite evidence showing that such a strategy may prevent a second and potentially more serious stroke, as reported in a study presented at ISC 2023.

In a cohort of 2,953 patients (mean age 67.3 years, 47.8 percent women, 60 percent White) admitted for TIA or minor AIS in one of the hospitals of the University of Maryland Stroke Clinical Network, only 40 percent were prescribed DAPT at the time of discharge. Notably, significantly more male than female patients received DAPT (43 percent vs 37 percent; p=0.002). [ISC 2023, abstract 43]

The number of DAPT prescribed also differed by body mass index (BMI) when this factor was included as a covariate. Specifically, patients with higher BMI were less likely to receive dual blood thinners. Then again, BMI had no independent effect on the number of antiplatelets prescribed.

Differences noted across subgroups defined by age, race, and whether the patient was discharged from a tertiary centre were not significant.

The gender gap in DAPT prescriptions, which could not be explained by differences in insurance coverage or in anticipated side effects of the medications, was not entirely surprising, according to Dr Jonathan Solomonow, lead study author and chief resident in neurology at the University of Maryland Medical Center in Baltimore, US.

“[T]here is extensive literature indicating that women with cardiovascular disease tend to be undertreated. For example, some studies show that women with heart disease or stroke are not prescribed statins as frequently as men. In addition, women with atrial fibrillation receive ablation less often than men,” Solomonow pointed out.

He called for further research to determine whether women are less likely to receive other proven therapies such as statins for stroke prevention and anticoagulation for atrial fibrillation.

“All stroke survivors, regardless of sex, should receive optimal proven medications for stroke prevention including DAPT when medically appropriate,” asserted Solomonow. [Stroke 2021;52:e364-e467]

“There are an increasing number of options available to prevent and reduce the risk of a recurrent stroke, including high blood pressure medications, statins to control cholesterol, and dual blood thinners. Patients and their family members should inquire about the use of DAPT after a stroke or TIA to consider if DAPT may be beneficial,” he added.

One of the study’s limitations is that the data were obtained from a single health system in Maryland, so the findings need to be validated in other settings, including hospitals that are not certified stroke centres.

“Identifying systemic inequities is essential to improving patient care across all demographics. It would be useful for other centres to explore whether sex differences are present in other parts of the US or healthcare systems in other countries,” according to Solomonow.