Aspirin, Clopidogrel, and Lacunar Stroke

Mark J. Alberts, MD


November 06, 2012

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Hello. I am Dr. Mark Alberts, Professor of Neurology at Northwestern University in Chicago. Welcome to this Medscape stroke update. Today I want to update you on a recent landmark study, called the SPS3, published recently in the New England Journal of Medicine.[1] SPS3 was a prospective, randomized, double-blind trial of patients with small-vessel lacunar strokes, who were randomly assigned to receive aspirin therapy alone or aspirin combined with clopidogrel.

The primary endpoint was any recurrent ischemic or hemorrhagic stroke. Patients were followed and treated for a mean of 3.4 years. At the end of the study, the rate of recurrent stroke was essentially identical: 2.5% vs 2.7%; they found no statistically significant difference between aspirin therapy alone vs aspirin plus clopidogrel [in this population].

The study did show a difference in the rate of major bleeds, which was essentially doubled in patients who received aspirin plus clopidogrel vs aspirin by itself. In addition, the overall mortality was also essentially doubled in patients who received combination therapy vs aspirin therapy by itself.

SPS3 is not the first study, but it may be the last study, to further examine the safety and efficacy of aspirin plus clopidogrel in patients with strokes. The study again found no difference in stroke recurrence rate but more bleeds and higher mortality for those patients taking dual therapy.

The ongoing POINT trial has a somewhat similar design but includes patients with TIAs or minor strokes. At endpoint, patients will have been treated for only 90 days, so we will see what that study shows. Again, SPS3 did not favor combination therapy as opposed to aspirin monotherapy. At this time, another component to SPS3 is comparing intense blood pressure control vs routine blood pressure control [in this population of patients]. Those results should be forthcoming.

Thank you very much for listening to this Medscape stroke update.