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Safety of Clopidogrel and Aspirin for Stroke Prevention

Implications of the CHARISMA trial

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Abstract

Antiplatelet therapy is universally recommended for the prevention of recurrent events in patients with noncardioembolic ischaemic stroke or transient ischaemic attack (TIA), acute and chronic coronary artery disease, or peripheral arterial disease. However, choosing which antiplatelet agents to use in these situations remains controversial. The use of aspirin, aspirin plus extended-release dipyridamole, or clopidogrel is recommended as initial therapy in patients with noncardioembolic ischaemic stroke or TIA to reduce the risk of recurrent stroke and other cardiovascular events. Based on the results of the MATCH trial, combination therapy with aspirin plus clopidogrel is not recommended for patients with ischaemic stroke or TIA due to the increased risk of haemorrhage.

The results of the CHARISMA trial support this recommendation; despite previous data demonstrating a favourable benefit-risk profile of aspirin plus clopidogrel in patients with acute coronary syndrome, this combination should not be used in patients at high risk for atherothrombosis and those with previous stroke or TIA. In these patients, the CHARISMA trial demonstrated a lack of significant clinical efficacy and an increased risk of bleeding with clopidogrel plus aspirin compared with aspirin alone.

Further research is needed to assess the benefit-risk ratio of clopidogrel plus aspirin in specific subpopulations of patients at high risk for atherothrombotic events, and to determine the role of clopidogrel plus aspirin in preventing cardioembolic stroke or early recurrent stroke after symptomatic large-vessel atherostenosis. Recent and ongoing studies are seeking to better define the roles of different antiplatelet regimens in preventing recurrent stroke.

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Acknowledgements

Editorial assistance for the preparation of this manuscript was provided by Johanna Grossman, Boehringer Ingelheim Pharmaceuticals, Inc. This work was supported by Boehringer Ingelheim Pharmaceuticals, Inc. The author has received speaking and/or consulting honoraria from Boehringer Ingelheim, Genentech, Novartis Pharmaceuticals and VasSol, Inc.

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  1. Section of Cerebrovascular Disease and Neurologic Critical Care, Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, Illinois, USA

    Sean Ruland

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  1. Sean Ruland
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Correspondence to Sean Ruland.

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Ruland, S. Safety of Clopidogrel and Aspirin for Stroke Prevention. Drug-Safety 31, 449–458 (2008). https://doi.org/10.2165/00002018-200831060-00001

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