Preventing Stroke Recurrence: Which Antiplatelet Strategy Is Best?

The best regimen of antiplatelet agents for the prevention of recurrent stroke has not been established. The Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) was an industry-sponsored, international study of strategies to reduce the risk for recurrent stroke. In the antiplatelet arm of the trial, 20,332 patients were randomized to receive clopidogrel or a combination of aspirin plus extended-release dipyridamole within 120 days after experiencing an ischemic stroke.

Mean patient age was 66, and about one third were women. A total of 6.7% had prior MI, and about one in six had a history of coronary artery disease. Over a mean of 30 months of follow-up, a first recurrent stroke occurred in 9.0% of the patients in the combination-therapy arm, compared with 8.8% of those in the clopidogrel arm (hazard ratio, 1.01; 95% confidence interval, 0.92–1.11); the upper limit of the CI for this comparison extended beyond the prespecified noninferiority margin of 1.075. The rate of combined stroke, MI, and death was identical in the two groups. MI occurred in 1.7% of the combination-therapy group and 1.9% of the clopidogrel group (HR, 0.90; 95% CI, 0.73–1.10). Major hemorrhagic events were more common in the combination-therapy group than in the clopidogrel group (4.1% vs 3.6%; HR, 1.15; 95% CI, 1.00–1.32).