Real-world comparison of dual versus single antiplatelet treatment in patients with non-cardioembolic mild-to-moderate ischemic stroke: A propensity matched analysis
Authors: Foschi Matteo , Ornello Raffaele , D’Anna Lucio , De Matteis Eleonora , De Santis Federico , Barone Valentina , Viola Marilina , Mosconi Maria Giulia , Rosin Diletta , Romoli Michele , Tassinari Tiziana , Cenciarelli Silvia , Censori Bruno , Zedde Marialuisa , Diomedi Marina , Petruzzellis Marco , Inchingolo Vincenzo , Cappellari Manuel , Candelaresi Paolo , Bavaro Alessandra , Cavallini Anna , Piscaglia Maria Grazia , Terruso Valeria , Pezzini Alessandro , Frisullo Giovanni , Muscia Francesco , Zini Andrea , Leone Ruggiero , Palmieri Carmela , Cupini Letizia Maria , Marcon Michela , Tassi Rossana , Sanzaro Enzo , Papiri Giulio , Viticchi Giovanna , Orsucci Daniele , Falcou Anne , Diamanti Susanna , Tarletti Roberto , Nencini Patrizia , Rota Eugenia , Sepe Federica Nicoletta , Caputi Luigi , Volpi Gino , La Spada Salvatore , Beccia Mario , Mastrangelo Vincenzo , Invernizzi Paolo , Pelliccioni Giuseppe , De Angelis Maria Vittoria , Bonanni Laura , Ruzza Giampietro , Caggia Emanuele Alessandro , Russo Monia , Tonon Agnese , Acciarri Maria Cristina , Anticoli Sabrina , Roberti Cinzia , Scaglione Gaspare , Pistoia Francesca , Alessi Chiara , De Boni Antonella , Sanna Alessandra , Chiti Alberto , Barbarini Leonardo , Masato Maela , Del Sette Massimo , Passarelli Francesco , Bongioanni Maria Roberta , De Michele Manuela , Ricci Stefano , Valente Mariarosaria , Gigli Gian Luigi , Merlino Giovanni , Paciaroni Maurizio , Guarino Maria , Sacco Simona 
Published: November 2024

Background: Short-term dual antiplatelet treatment (DAPT) is superior to single antiplatelet treatment (SAPT) for secondary prevention in non-cardioembolic minor ischemic stroke and high-risk transient ischemic attack (TIA). As the real-world use of DAPT is broader than in trials, it is important to clarify its benefit/risk profile in a diverse population. Methods: Post hoc analysis of prospectively collected data from the READAPT cohort and three prospective stroke registries including patients with mild-to-moderate (National Institute of Health Stroke Scale (NIHSS) score 0–10) ischemic stroke receiving early DAPT or SAPT. The primary effectiveness outcome was 90-day return to pre-stroke neurological functioning using modified Rankin Scale (mRS) score. Secondary effectiveness outcomes were 90-day mRS shift, new ischemic stroke/TIA, vascular and all-cause death, 24 h early neurological improvement or deterioration. The safety outcome was 90-day intracranial hemorrhage. Results: We matched 1008 patients treated with DAPT and 1008 treated with SAPT. Compared to SAPT, patients treated with DAPT showed higher likelihood of 90-day primary effectiveness outcome (87.5% vs. 84.4%, risk difference 3.1% (95% confidence interval (CI): 0.1%–6.1%); p = 0.047, risk ratio 1.03 (95% CI: 1.01–1.07); p = 0.043) and higher rate of 24-h early neurological improvement (25.3% vs. 15.4%, risk difference 9.9% (95% CI: 6.4%–13.4%); p < 0.001, risk ratio 1.65 (95% CI: 1.37–1.97); p < 0.001). No differences were observed for other study outcomes. Subgroup analysis confirmed benefit of DAPT over SAPT for primary effectiveness outcome in patients with moderate stroke, those treated with intravenous thrombolysis, and those who received antiplatelet loading dose. Conclusion: Our findings suggest that DAPT use might be safe and more effective than SAPT even in the real world and in patients who do not strictly fulfill the criteria of landmark large clinical trials.