By Matthew E. Fink, MD
Professor and Chairman, Department of Neurology, Weill Cornell Medical College; Neurologist-in-Chief, New York Presbyterian Hospital
Dr. Fink reports he is a retained consultant for Procter & Gamble and Pfizer.
Johnston SC, Easton JD, Farrant M, et al; Clinical Research Collaboration, Neurological Emergencies Treatment Trials Network and the POINT Investigators. Clopidogrel and aspirin in acute ischemic stroke and high-risk TIA. N Engl J Med 2018;379:215-225.
In a recent study of a Chinese population, early treatment with dual antiplatelet medications demonstrated a reduction in the risk of recurrent stroke. The POINT trial included an international population to test the hypothesis that early treatment of minor ischemic stroke or high-risk transient ischemic attack (TIA) with a combination of clopidogrel and aspirin would be better than aspirin alone in reducing the incidence of recurrent ischemic stroke at 90 days. POINT was a randomized trial that enrolled 4,881 patients at 269 sites. The trial was halted early after 84% of the anticipated number of patients were enrolled, because an interim analysis showed that the combination of clopidogrel and aspirin was associated with a lower risk of major ischemic events but a higher risk of major hemorrhage than aspirin alone at 90 days.
Major ischemic events occurred in 5% of patients receiving clopidogrel plus aspirin and in 6.5% of patients receiving aspirin plus placebo (hazard ratio, 0.75; P = 0.02). Most of the recurrent ischemic events occurred during the first week following initial event. Major hemorrhages occurred in 0.9% of patients receiving dual antiplatelet therapy and 0.4% of patients receiving aspirin plus placebo. The most feared complication, symptomatic intracerebral hemorrhage, was rare in both groups, and there were only two cases in each group (0.1%). Most serious hemorrhages that occurred were related to gastrointestinal bleeding. Although dual antiplatelet therapy conferred modest benefit regarding recurrent ischemic events, the increased risk of serious hemorrhages must be taken into account when making therapeutic decisions to use these medications in combination.
