Ticagrelor, Clopidogrel With Aspirin Effective in Stroke Recurrence Prevention

Compared with aspirin alone, ticagrelor and aspirin or clopidogrel and aspirin are more effective in the prevention of ischemic stroke recurrence.

Dual antiplatelet therapy (DAPT) using aspirin combined either with ticagrelor or clopidogrel is more effective than using aspirin alone. Outcomes using either DAPT regimen did not significantly differ; however, Asian populations may benefit more from DAPT using ticagrelor plus aspirin. These are the findings of a study published in the journal BMC Neurology

Studies have shown that DAPT using clopidogrel plus aspirin is superior than aspirin alone to reduce the risk for stroke recurrence within the first 90 days in individuals after experiencing a minor ischemic stroke or transient ischemic attack (TIA). Individuals with CYP2C19 genetic polymorphisms responded poorly to clopidogrel, the efficacy of which depends on metabolic activation.

Ticagrelor is a reversible P2Y12 receptor antagonist, which does not require metabolic activation in the liver like clopidogrel. Researchers have not compared the efficacy and safety of DAPT using ticagrelor plus aspirin to DAPT using clopidogrel plus aspirin for the prevention of ischemic stroke recurrence.  

Researchers in China conducted a systematic review and meta-analysis of the literature published up until June 19, 2023 to evaluate available evidence and compare the efficacy and safety of ticagrelor plus aspirin vs clopidogrel plus aspirin in the prevention of stroke recurrence. They identified 7 eligible randomized controlled trials with a total of 41,745 participants, which they included in their network meta-analysis.

DAPT was superior to aspirin in stroke prevention, but little difference existed between the two DAPT regimens.

The 2 DAPTs did not differ significantly in their ability to prevent stroke recurrence (odds ratio [OR], 1.16; 95% CI, 0.93-1.44), ischemic stroke recurrence (OR, 1.16; 95% CI, 0.93-1.45; or major hemorrhage OR 1.22; 95% CI, 0.62-2.39).

Both DAPTs were more effective than aspirin alone in reducing stroke recurrence (OR of clopidogrel plus aspirin, 0.69; 95% CI, 0.60-0.80) and (OR of ticagrelor plus aspirin, 0.66; 95% CI, 0.49-0.87). Ticagrelor, in particular, was more effective than aspirin (OR, 0.80; 95% CI, 0.68-0.94).

In contrast, both DAPTs increased the incidence of major hemorrhage compared with aspirin alone (OR of clopidogrel plus aspirin, 2.05; 95% CI, 1.22-3.77 vs OR of ticagrelor, 2.55; 95% CI, 1.25-4.99). DAPT with ticagrelor plus aspirin increased the risk for any bleeding more so than DAPT with clopidogrel plus aspirin (OR, 1.97; 95% CI, 1.21-3.22).

The researchers analyzed a subgroup consisting of 4 randomized controlled trials with 16,115 (mainly Chinese) participants. They discovered that in this predominantly Asian cohort, compared with clopidogrel plus aspirin, ticagrelor plus aspirin successfully reduced ischemic stroke recurrence (OR, 0.77; 95% CI, 0.63-0.92) without consequently increasing the risk for major bleeding (OR, 0.94; 95% CI, 0.45-1.95).

“DAPT was superior to aspirin in stroke prevention, but little difference existed between the [2] DAPT regimens,” the researchers concluded.

Study limitations included the heterogeneity of study sample sizes and designs, treatment regimens, endpoint criteria, and follow-up durations for all included studies. Publication bias was another potential study limitation.

This article originally appeared on Neurology Advisor


Li M, Yang Q, Shi J, Zhang X, Lin H, Ge F. Ticagrelor plus aspirin in patients with minor ischemic stroke and transient ischemic attack: a network meta-analysis. BMC Neurol. Published online August 14, 2023. doi:10.1186/s12883-023-03356-7