After multivariable adjustment, DAPT prior to DOAC initiation was not independently associated with better functional outcomes compared to SAPT, and the apparent crude benefit was 'largely attributable to selection bias rather than a true therapeutic advantage of DAPT.'
Key Findings
Results
In unadjusted analysis, DAPT was associated with higher 90-day favorable functional outcome compared to SAPT, but this difference did not reach significance after adjustment.
Unadjusted 90-day favorable outcome (mRS 0-2): 90.3% (DAPT) vs. 75.0% (SAPT), p = 0.046
After multivariable adjustment, DAPT was not independently associated with mRS 0-2 (adjusted OR 2.40, 95% CI 0.62–10.06, p = 0.211)
DAPT was also not independently associated with excellent outcome mRS 0-1 (adjusted OR 1.18, 95% CI 0.43–3.14, p = 0.739)
Ordinal mRS shift analysis similarly showed no independent association with DAPT (adjusted common OR 0.70, 95% CI 0.34–1.44, p = 0.336)
Results
Baseline NIHSS score independently predicted all short-term and long-term outcomes.
Baseline NIHSS independently predicted early neurological improvement, early neurological deterioration, 90-day mRS 0-2, 90-day mRS 0-1, and ordinal mRS shift (p < 0.001 for all)
Median baseline NIHSS was 4.00 in the SAPT group vs. 2.00 in the DAPT group, though this difference was not statistically significant (p = 0.136)
The authors attribute the crude DAPT benefit to selection bias, with milder strokes being more likely assigned to DAPT
Results
There were no significant differences in early neurological improvement or early neurological deterioration between SAPT and DAPT groups.
Early neurological improvement (≥2-point NIHSS reduction): 39.6% (SAPT) vs. 37.5% (DAPT), p = 0.969
Early neurological deterioration (≥4-point NIHSS increase or death within 48 h): 4.2% (SAPT) vs. 0% (DAPT), p = 0.158
Study included 120 patients total: SAPT n = 48, DAPT n = 72
Results
In-hospital bleeding events did not differ significantly between SAPT and DAPT groups.
Bleeding events: 6.2% (SAPT) vs. 1.4% (DAPT), p = 0.301
The numerical trend was toward more bleeding in the SAPT group, though this was not statistically significant
These findings suggest DAPT did not confer excess bleeding risk in this population
Methods
Baseline characteristics were comparable between the SAPT and DAPT groups.
Baseline NIHSS score: median 4.00 (SAPT) vs. 2.00 (DAPT), p = 0.136
Baseline mRS score: median 3.00 vs. 3.00, p = 0.435
This was a single-center retrospective cohort study with 120 patients with AIS and NVAF who received antiplatelet therapy prior to DOAC initiation
Conclusions
The study's authors concluded that current data do not support the superiority of DAPT over SAPT as a bridging strategy before DOAC initiation.
The apparent crude benefit of DAPT was attributed to selection bias rather than a true therapeutic advantage
Authors described findings as 'hypothesis-generating' and called for 'adequately powered prospective randomized trials' to confirm results
The optimal antiplatelet bridging strategy before DOAC initiation in AIS with NVAF remains uncertain based on these data
What This Means
This research studied 120 patients who had both an acute ischemic stroke (a stroke caused by a blood clot) and a heart rhythm disorder called atrial fibrillation. These patients all received antiplatelet medications (blood-thinning drugs like aspirin or clopidogrel) before starting a newer class of anticoagulants called direct oral anticoagulants (DOACs). The study compared patients who took just one antiplatelet drug (single antiplatelet therapy, SAPT) to those who took two at once (dual antiplatelet therapy, DAPT), looking at outcomes including short-term brain function changes, bleeding complications, and how well patients recovered at 90 days.
At first glance, patients on DAPT appeared to do better at 90 days — 90.3% had a good functional recovery compared to 75.0% in the SAPT group. However, when the researchers accounted for how severe the strokes were at the start, this advantage disappeared entirely. The key factor predicting recovery was the stroke severity at admission (measured by the NIHSS score), not whether patients received one or two antiplatelet drugs. There were also no significant differences in early brain function changes or in-hospital bleeding between the two groups, suggesting DAPT did not cause extra harm but also did not provide clear benefit.
This research suggests that using two antiplatelet drugs instead of one before starting DOACs in stroke patients with atrial fibrillation does not appear to provide a meaningful advantage in recovery. The study's authors caution that their findings are preliminary — based on a relatively small, single-center retrospective study — and that larger, prospective randomized trials are needed to definitively answer whether one approach is better than the other. Stroke severity at the time of hospital admission was the strongest predictor of both short-term and longer-term outcomes.
Hou G, Tuersun A, Wang Z, Chen H, Dang D, Zhao Q, et al.. (2026). Single vs. dual antiplatelet therapy before DOAC initiation in acute ischemic stroke with atrial fibrillation: a retrospective cohort study.. Frontiers in neurology. https://doi.org/10.3389/fneur.2026.1882830