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Listen "Aspirin Alone or Dual Antiplatelet Therapy (DAPT) with Clopidogrel? The Hospitalist's Guide to Early Stroke Recurrence Prevention"
Episode Synopsis
In this episode of Hospital Medicine Unplugged, we get practical about single vs dual antiplatelet therapy after ischemic stroke—who gets what, for how long, and when DAPT does more harm than good.
We start by framing the landscape: noncardioembolic vs cardioembolic stroke, small-vessel vs large-artery disease, and why platelets are center stage in atherothrombotic stroke but not in AF-driven cardioembolism.
Then we walk through who actually qualifies for DAPT:
Minor noncardioembolic ischemic stroke (NIHSS ≤3)
High-risk TIA (ABCD² ≥4)
Select mild-to-moderate strokes (up to NIHSS 5) and large-artery atherosclerosis / intracranial stenosis, where data for intensified therapy are emerging.
We lay out exact protocols you can copy into your order sets:
Classic aspirin + clopidogrel: loading, maintenance, and how to transition cleanly to SAPT.
Ticagrelor + aspirin: when to prefer it (e.g., CYP2C19 loss-of-function) and how to factor in the higher bleeding signal.
Why triple therapy is a hard no.
A big chunk of the episode is “how long is long enough?”:
Why the real benefit of DAPT is front-loaded into the first 10–21 days.
How CHANCE, POINT, THALES, and meta-analyses sharpen the message: short-term DAPT cuts early recurrence; longer DAPT mainly buys bleeding.
Why most patients should land on ~21 days of DAPT, then SAPT indefinitely, and when 30–90 days might still make sense (e.g., intracranial stenosis, stenting protocols).
We also spell out when NOT to use DAPT:
Moderate–severe stroke with big infarcts and hemorrhagic risk
Cardioembolic stroke (AF, LV thrombus, valvular disease) where anticoagulation wins
Lacunar stroke, where SPS3 showed more bleeding without benefit
Patients with high bleeding risk or prior GI bleed, thrombocytopenia, or hemorrhagic transformation
ESUS and other gray zones where DAPT has no proven upside.
Finally, we zoom out to long-term secondary prevention:
Choosing between aspirin, clopidogrel, and aspirin–dipyridamole
Why clopidogrel often has the best net clinical profile (similar efficacy, less major bleeding)
How to build a stroke unit habit: NIHSS + ABCD² on arrival, early mechanism workup, tight DAPT stop dates, and defaulting back to SAPT instead of “set-and-forget” dual therapy.
If you’ve ever wondered “Should this patient be on DAPT, for how long, and what am I risking?” this episode gives you a crisp, evidence-based playbook you can use on your next stroke admission.
We start by framing the landscape: noncardioembolic vs cardioembolic stroke, small-vessel vs large-artery disease, and why platelets are center stage in atherothrombotic stroke but not in AF-driven cardioembolism.
Then we walk through who actually qualifies for DAPT:
Minor noncardioembolic ischemic stroke (NIHSS ≤3)
High-risk TIA (ABCD² ≥4)
Select mild-to-moderate strokes (up to NIHSS 5) and large-artery atherosclerosis / intracranial stenosis, where data for intensified therapy are emerging.
We lay out exact protocols you can copy into your order sets:
Classic aspirin + clopidogrel: loading, maintenance, and how to transition cleanly to SAPT.
Ticagrelor + aspirin: when to prefer it (e.g., CYP2C19 loss-of-function) and how to factor in the higher bleeding signal.
Why triple therapy is a hard no.
A big chunk of the episode is “how long is long enough?”:
Why the real benefit of DAPT is front-loaded into the first 10–21 days.
How CHANCE, POINT, THALES, and meta-analyses sharpen the message: short-term DAPT cuts early recurrence; longer DAPT mainly buys bleeding.
Why most patients should land on ~21 days of DAPT, then SAPT indefinitely, and when 30–90 days might still make sense (e.g., intracranial stenosis, stenting protocols).
We also spell out when NOT to use DAPT:
Moderate–severe stroke with big infarcts and hemorrhagic risk
Cardioembolic stroke (AF, LV thrombus, valvular disease) where anticoagulation wins
Lacunar stroke, where SPS3 showed more bleeding without benefit
Patients with high bleeding risk or prior GI bleed, thrombocytopenia, or hemorrhagic transformation
ESUS and other gray zones where DAPT has no proven upside.
Finally, we zoom out to long-term secondary prevention:
Choosing between aspirin, clopidogrel, and aspirin–dipyridamole
Why clopidogrel often has the best net clinical profile (similar efficacy, less major bleeding)
How to build a stroke unit habit: NIHSS + ABCD² on arrival, early mechanism workup, tight DAPT stop dates, and defaulting back to SAPT instead of “set-and-forget” dual therapy.
If you’ve ever wondered “Should this patient be on DAPT, for how long, and what am I risking?” this episode gives you a crisp, evidence-based playbook you can use on your next stroke admission.
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