Effectiveness and safety of different antiplatelet therapies for minor ischemic stroke or high-risk transient ischemic attack: a systematic review and network meta-analysis.

INTRODUCTION

Approximately one-third of patients with minor ischemic stroke (MIS) and transient ischemic attack (TIA) fail to achieve functional independence due to stroke progression or recurrent stroke. Identifying effective secondary prevention strategies is crucial to reduce morbidity, mortality, and disability.

AIM: This systematic review and network meta-analysis aimed to evaluate the effectiveness and safety of various antiplatelet therapies using network meta-analysis and to identify the optimal treatment option for patients with MIS or high-risk TIA.

METHOD: Studies were retrieved from PubMed, Embase, Web of Science, and Cochrane Library from inception to August 29, 2024. Randomized controlled trials (RCTs) and observational studies comparing antiplatelet treatments for MIS or high-risk TIA were included through consensus. The primary outcome was recurrent strokes. The secondary outcomes included recurrent ischemic strokes and a composite outcome combining ischemic stroke, myocardial infarction, and vascular death. The safety outcomes included intracerebral hemorrhage (ICH), any bleeding events, and all-cause mortality. Treatments were ranked based on the surface under the cumulative rank curve (SUCRA).

RESULTS

Nineteen studies, including 12 RCTs and seven observational studies with 90,483 patients, were analyzed. Compared with aspirin or other mono antiplatelet therapies, both dual antiplatelet therapies of clopidogrel plus aspirin and ticagrelor plus aspirin reduced the risk of recurrent strokes, recurrent ischemic strokes, and the composite outcome without increasing the risk of ICH or all-cause mortality. However, ticagrelor plus aspirin significantly increased the risk of any bleeding. This treatment had the highest SUCRA score (0.97) for the primary outcome and the lowest (0.01) for any bleeding.

CONCLUSION

Based on the combined results of effectiveness and safety, clopidogrel plus aspirin may be the optimal choice. However, for patients with a low bleeding risk, ticagrelor plus aspirin serves as an appropriate alternative.