The following are key points to remember from this review on antiplatelet regimens for patients with breakthrough strokes while on aspirin:

1. The best antiplatelet therapy after a patient has an ischemic stroke or transient ischemic attack (TIA) while on aspirin monotherapy (“aspirin failure”) is uncertain: Should the antiplatelet regimen be modified, or should aspirin monotherapy be continued?
2. A meta-analysis of five relevant cohort and randomized controlled studies (enrolling 8,723 patients) found that adding an antiplatelet agent to aspirin monotherapy, or switching to another antiplatelet therapy, was associated with a 32% reduced risk of major adverse cardiovascular events (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.54-0.85).
3. A meta-analysis of four relevant cohort and randomized controlled studies (enrolling 4,491 patients) found that adding an antiplatelet agent to aspirin monotherapy, or switching to another antiplatelet therapy, was associated with a 30% reduced risk of recurrent ischemic or hemorrhagic stroke (HR, 0.70; 95% CI, 0.54-0.92).
4. These results suggest a benefit of changing the antiplatelet regimen in patients with ischemic stroke or TIA while on aspirin monotherapy. A randomized controlled trial of different antiplatelet strategies in TIA/stroke patients with “aspirin failure” is indicated prior to guideline change.

Keywords: Aspirin, Intracranial Hemorrhages, Ischemic Attack, Transient, Platelet Aggregation Inhibitors, Primary Prevention, Risk Factors, Stroke, Vascular Diseases

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