Dual Antiplatelet Therapy After Stroke or TIA

Short-course DAPT (clopidogrel + aspirin for 21 days, then aspirin monotherapy) reduces 90-day stroke recurrence by approximately 25% in minor ischemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4) — established by CHANCE (2013, China) and confirmed by POINT (2018, North America). THALES (2020) showed ticagrelor + aspirin also works. CHANCE-2 (2021) addressed CYP2C19 loss-of-function carriers with ticagrelor. INSPIRES (2024) extended DAPT to atherosclerotic minor stroke/TIA within 72 h. SPS3 (2012) showed long-term DAPT for lacunar stroke causes net harm — duration must be limited to ~21 days.

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Clinical Question

DAPT after stroke or TIA. Yes or no?

Synthesises 8 trialsdual antiplatelet for TIA and minor ischaemic stroke, with duration and population boundaries

What does the guideline say?

§4.8 Antiplatelet TreatmentLOE A· 2026
In patients with minor (NIHSS score ≤3) noncardioembolic AIS or high-risk TIA (ABCD² score ≥4) who did not receive IVT, DAPT (aspirin and clopidogrel with loading dose of clopidogrel) should be initiated early (within 24 hours after symptom onset) and continued for 21 days, followed by single antiplatelet therapy (SAPT) to reduce the 90-day risk of recurrent ischemic stroke.
Source: 2026 AHA/ASA Guideline — §4.8 (Antiplatelet Treatment — DAPT for minor noncardioembolic AIS or high-risk TIA)

The trials cited in the guideline's supportive text appear below.

Trials in this question· 8

SPS32012

HarmNo benefit; ↑bleed

Long-term DAPT (clopidogrel+aspirin) in lacunar stroke increases mortality and bleeding with no stroke reduction.

HarmNo benefit; ↑bleed

CHANCE2013

NNT 29ARR 3.5%

Clopidogrel + aspirin × 21 d after minor stroke or high-risk TIA cuts 90-d stroke vs aspirin alone.

NNT 29ARR 3.5%

SOCRATES2016

NSARR 0.8% (NS)