Early dual antiplatelet therapy in stroke: should we take the CHANCE?

Patients with stroke or transient ischemic attack (TIA) are at high risk of recurrence. Approximately 10-20% of patients have another stroke within the first 3 months of the index event. Recurrent strokes can be disabling for patients, sometimes resulting in fatal consequences. The role of aspirin has been established in the acute phase as well as in secondary prevention of future ischemic strokes. Clopidogrel, an inhibitor of adenosine diphosphate (ADP) receptor on platelet cell membranes, along with aspirin synergistically prevents platelet activation and further ischemic events. Beneficial effects of this dual antiplatelet therapy (DAPT) in acute coronary syndromes have been established, without any increased risk of bleeding, however the same cannot be said about secondary prevention of stroke. In the acute phase, ischemic strokes are prone to hemorrhagic transformation spontaneously and a recently published meta-analysis of five randomized controlled trials, which enrolled patients with acute ischemic stroke or TIA, reported an increase in major bleeding with the combination therapy.