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Comparative Study
. 2025 Apr;20(4):438-449.
doi: 10.1177/17474930241302991. Epub 2024 Dec 16.

Real-world comparison of dual versus single antiplatelet treatment in patients with non-cardioembolic mild-to-moderate ischemic stroke: A propensity matched analysis

Matteo Foschi  1 , Raffaele Ornello  1 , Lucio D'Anna  2   3 , Eleonora De Matteis  1   2 , Federico De Santis  1 , Valentina Barone  4 , Marilina Viola  4 , Maria Giulia Mosconi  5 , Diletta Rosin  6   7 , Michele Romoli  8 , Tiziana Tassinari  9 , Silvia Cenciarelli  10 , Bruno Censori  11 , Marialuisa Zedde  12 , Marina Diomedi  13 , Marco Petruzzellis  14 , Vincenzo Inchingolo  15 , Manuel Cappellari  16 , Paolo Candelaresi  17 , Alessandra Bavaro  18 , Anna Cavallini  19 , Maria Grazia Piscaglia  20 , Valeria Terruso  21 , Alessandro Pezzini  22   23 , Giovanni Frisullo  24 , Francesco Muscia  25 , Andrea Zini  26 , Ruggiero Leone  27 , Carmela Palmieri  28 , Letizia Maria Cupini  29 , Michela Marcon  30 , Rossana Tassi  31 , Enzo Sanzaro  32 , Giulio Papiri  33 , Giovanna Viticchi  34 , Daniele Orsucci  35 , Anne Falcou  36 , Susanna Diamanti  37 , Roberto Tarletti  38 , Patrizia Nencini  39 , Eugenia Rota  40 , Federica Nicoletta Sepe  41 , Luigi Caputi  42 , Gino Volpi  43 , Salvatore La Spada  44 , Mario Beccia  45 , Vincenzo Mastrangelo  46 , Paolo Invernizzi  47 , Giuseppe Pelliccioni  48 , Maria Vittoria De Angelis  49 , Laura Bonanni  50 , Giampietro Ruzza  51 , Emanuele Alessandro Caggia  52 , Monia Russo  53 , Agnese Tonon  54 , Maria Cristina Acciarri  55 , Sabrina Anticoli  56 , Cinzia Roberti  57 , Gaspare Scaglione  58 , Francesca Pistoia  1 , Chiara Alessi  59 , Antonella De Boni  60 , Alessandra Sanna  61 , Alberto Chiti  62 , Leonardo Barbarini  63 , Maela Masato  64 , Massimo Del Sette  65 , Francesco Passarelli  66 , Maria Roberta Bongioanni  67 , Manuela De Michele  68 , Stefano Ricci  10   69 , Mariarosaria Valente  6   7 , Gian Luigi Gigli  6   7 , Giovanni Merlino  6   7 , Maurizio Paciaroni  5 , Maria Guarino  4 , Simona Sacco  1
Affiliations
Comparative Study

Real-world comparison of dual versus single antiplatelet treatment in patients with non-cardioembolic mild-to-moderate ischemic stroke: A propensity matched analysis

Matteo Foschi et al. Int J Stroke. 2025 Apr.

Abstract

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.

Keywords: Ischemic stroke; aspirin; dual antiplatelet treatment; mild-to-moderate; outcomes; prognosis.

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Conflict of interest statement

Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: AZ reports compensation from Angels Initiative, Boehringer-Ingelheim, Daiichi Sankyo for consultant services; from Angels Initiative, Boehringer-Ingelheim, CSL Behring for speaking honoraria or other education services; from Daiichi Sankyo for meeting; from Bayer, and Astra Zeneca for participation on a Data Safety, Monitoring or Advisory Board; he is member of ESO guidelines, ISA-AII guidelines, and IRETAS steering committee. RO reports grants from Novartis and Allergan; compensation from Teva Pharmaceutical Industries, Eli Lilly and Company, and Novartis for other services; and travel support from Teva Pharmaceutical Industries. SS reports compensation from Novartis, NovoNordisk, Allergan, AstraZeneca, Pfizer Canada, Inc, Eli Lilly and Company, Teva Pharmaceutical Industries, H. Lundbeck A/S, and Abbott Canada for consultant services; compensation from Novartis for other services. MP reports compensation from Daiichi Sankyo Company, Bristol Myers Squibb, Bayer, and Pfizer Canada, Inc., for consultant services. The other authors report no conflicts.

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