Clopidogrel Added to Aspirin Adds No Benefit but Bleeding Risk in Patients With Recent Lacunar Stroke

Patients with transient ischemic attack or ischemic stroke have a high risk of recurrent stroke. Antiplatelet therapy has shown efficacy in secondary stroke prevention and is recommended by guidelines.1–3 In patients without cardiac source of embolism aspirin, clopidogrel or the combination of aspirin and dipyridamole is recommended.In cardiology, the combination of aspirin and clopidogrel was superior to aspirin monotherapy in the prevention of vascular events after acute coronary syndrome4 but carried a higher bleeding risk. In patients with atrial fibrillation the combination of aspirin plus clopidogrel was superior to aspirin alone in preventing strokes,5 but was again associated with a significant higher risk of major bleeds. In early secondary stroke prevention after transient ischemic attack or minor stroke combination, antiplatelet therapy seems to be superior to monotherapy, but larger randomized trials are needed.6,7Combination antiplatelet therapy carries a consistent higher risk of major bleeding complications than monotherapy. Therefore, the possible benefit of a reduction in vascular events has to be balanced against the bleeding risk, especially in stroke patients. In the Management of Atherothrombosis with Clopidogrel in High-risk patients (MATCH) trial, aspirin plus clopidogrel was investigated against aspirin monotherapy in high-risk patients with recent transient ischemic attack or ischemic stroke.8 Similar to the Secondary Prevention of Small Subcortical Strokes (SPS3) trial, patients with a cardiac source of embolism and significant carotid stenosis requiring surgery were excluded. About 50% of patients were categorized to have small vessel disease with suspected lacunar strokes, but in contrast to the SPS3 trial, …