What’s the evidence for 21 days of DAPT after TIA or minor stroke?
Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack (CHANCE)
Wang Y et al. NEJM (July 2013)
Bottom Line: This randomized, double-blind, placebo-controlled trial evaluated the effectiveness of clopidogrel in addition to aspirin in protecting against subsequent stroke after a transient ischemic attack (TIA) or minor ischemic stroke. 5170 patients who were within 24 hours after the onset of a minor ischemic stroke or high-risk TIA were randomly assigned to either combination therapy with clopidogrel plus aspirin (clopidogrel 300 mg initial dose followed by 75 mg daily for 90 days plus aspirin 75 mg daily for 21 days) or placebo plus aspirin (75 mg daily for 90 days). The primary outcome was ischemic or hemorrhagic stroke within 90 days of follow up. Stroke occurred in 8.2% of patients in the clopidogrel–aspirin group, as compared with 11.7% of those in the aspirin group (hazard ratio, 0.68; 95% confidence interval, 0.57 to 0.81; P<0.001). The rates of moderate or severe hemorrhage and hemorrhagic stroke were similar in both groups. Thus, in patients with TIA or minor stroke within 24 hours of symptom onset, a combination clopidogrel and aspirin were found to be superior to aspirin alone in reducing the risk of subsequent stroke in the first 90 days, and did not increase the risk of hemorrhage.
Why should I not routinely repeat stress testing one year after PCI?
Routine Functional Testing or Standard Care in High-Risk Patients after PCI (POST-PCI)
Park, DW et al. NEJM (August 2022)
Bottom Line: This randomized trial evaluated whether a follow-up strategy that includes routine functional testing improves clinical outcomes among high-risk patients who have undergone PCI. The study included 1706 patients with high-risk anatomical or clinical characteristics who were randomly assigned to receive either routine functional testing or standard care alone at 1 year after PCI. The primary outcome was a composite of death, myocardial infarction, or hospitalization for unstable angina at 2 years. The results showed no significant difference in the primary outcome between the two groups. At 2 years, 12.3% of patients in the functional-testing group and 9.3% in the standard-care group had undergone invasive coronary angiography (difference, 2.99 percentage points; 95% CI, −0.01 to 5.99), and 8.1% and 5.8% of patients, respectively, had undergone repeat revascularization (difference, 2.23 percentage points; 95% CI, −0.22 to 4.68). There were also no significant differences in safety outcomes or secondary outcomes such as invasive coronary angiography and repeat revascularization. In conclusion, routine functional testing did not improve clinical outcomes at 2 years for high-risk patients who had undergone PCI.
What’s the rationale for using rifampicin as adjunctive therapy for staph aureus bacteremia?
Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial
Thwaites, GE et al. The Lancet (February 2018)
Bottom Line: This multicentre, randomized, double-blind, placebo-controlled trial investigated the effectiveness of adjunctive rifampicin in reducing treatment failure, disease recurrence, or death in adults with S. aureus bacteraemia. A total of 758 participants from 29 UK hospitals were randomly assigned to receive either adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) or placebo, in addition to standard antibiotic therapy. The primary outcome was time to treatment failure, disease recurrence, or all-cause death within 12 weeks. Results showed no significant difference between the two groups at 12 weeks. However, more participants in the rifampicin group experienced adverse events related to antibiotics or the trial drug, as well as drug interactions. Therefore, adjunctive rifampicin did not provide overall benefit in this patient population.
Trial Files Issue #2025-02