***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : To assess whether adding clopidogrel to acetylsalicylic acid ( ASA ) has a long-term protective vascular effect in patients with lacunar stroke while taking ASA . Methods : Post hoc analysis of 838 patients with ASA failure and recent lacunar stroke from the Secondary Prevention of Small Subcortical Strokes Trial ( SPS3 ) cohort r and omly allocated to aspirin ( 325 mg/day ) and clopidogrel ( 75 mg/day ) or placebo . Primary efficacy outcome was stroke recurrence ( ischemic and intracranial hemorrhage ) and main safety outcome was major extracranial hemorrhage . Patients were followed for a mean period of 3.5 years . Results : The ASA failure group had a significantly higher risk of vascular events including ischemic stroke when compared with the non – ASA failure group ( n = 2,151 ) in SPS3 ( p = 0.03 ) . Mean age was 65.6 years and 65 % were men . The risk of recurrent stroke was not reduced in the dual antiplatelet group , 3.1 % per year , compared to the aspirin-only group , 3.3 % per year ( hazard ratio [ HR ] 0.91 ; 95 % confidence interval [ CI ] 0.61–1.37 ) . There was also no difference between groups for ischemic stroke ( HR 0.90 ; 95 % CI 0.59–1.38 ) . The risk of gastrointestinal bleeding was higher in the dual antiplatelet group ( HR 2.7 ; 95 % CI 1.1–6.9 ) ; however , the risk of intracranial hemorrhage was not different . Conclusions : In patients with a recent lacunar stroke while taking ASA , the addition of clopidogrel did not result in reduction of vascular events vs continuing ASA only . Classification of evidence : This study provides Class I evidence that for patients with recent lacunar stroke while taking ASA , adding clopidogrel as compared to continuing ASA alone does not reduce the risk of recurrent stroke BACKGROUND Patients with transient ischaemic attack ( TIA ) or minor stroke are at high immediate risk of stroke . The optimum early treatment options for these patients are not known . METHODS Within 24 h of symptom onset , we r and omly assigned , in a factorial design , 392 patients with TIA or minor stroke to clopidogrel  ( 300 mg loading dose then 75 mg daily ; 198 patients ) or placebo ( 194 patients ) , and simvastatin ( 40 mg daily ; 199 patients ) or placebo ( 193 patients ) . All patients were also given aspirin and were followed for 90 days . Descriptive analyses were done by intention to treat . The primary outcome was total stroke ( ischaemic and haemorrhagic ) within 90 days . Safety outcomes included haemorrhage related to clopidogrel and myositis related to simvastatin . This study is registered as an International St and ard R and omised Controlled Trial ( number 35624812 ) and with Clinical Trials.gov ( NCT00109382 ) . FINDINGS The median time to stroke outcome was 1 day ( range 0 - 62 days ) . The trial was stopped early due to a failure to recruit patients at the prespecified minimum enrolment rate because of increased use of statins . 14 ( 7.1 % ) patients on clopidogrel had a stroke within 90 days compared with 21 ( 10.8 % ) patients on placebo ( risk ratio 0.7 [ 95 % CI 0.3 - 1.2 ] ; absolute risk reduction -3.8 % [ 95 % CI -9.4 to 1.9 ] ; p=0.19 ) . 21 ( 10.6 % ) patients on simvastatin had a stroke within 90 days compared with 14 ( 7.3 % ) patients on placebo ( risk ratio 1.3 [ 0.7 - 2.4 ] ; absolute risk increase 3.3 % [ -2.3 to 8.9 ] ; p=0.25 ) . The interaction between clopidogrel and simvastatin was not significant ( p=0.64 ) . Two patients on clopidogrel had intracranial haemorrhage compared with none on placebo ( absolute risk increase 1.0 % [ -0.4 to 2.4 ] ; p=0.5 ) . There was no difference between groups for the simvastatin safety outcomes . INTERPRETATION Immediately after TIA or minor stroke , patients are at high risk of stroke , which might be reduced by using clopidogrel in addition to aspirin . The haemorrhagic risks of the combination of aspirin and clopidogrel do not seem to offset this potential benefit . We were unable to provide evidence of benefit of simvastatin in this setting . This aggressive prevention approach merits further study BACKGROUND Few r and omised clinical trials have investigated the use of antithrombotic drugs for early secondary prevention of stroke or transient ischaemic attack in patients with intracranial atherosclerotic stenosis . Microembolic signals , detected by transcranial doppler , are a surrogate marker of future stroke risk and have been used to show treatment efficacy in patients with extracranial carotid stenosis . We aim ed to investigate whether treatment with clopidogrel plus aspirin reduced the number of microembolic signals detected with transcranial doppler ultrasound compared with aspirin alone in patients with recent stroke . METHODS The clopidogrel plus aspirin for infa rct ion reduction in acute stroke or transient ischaemic attack patients with large artery stenosis and microembolic signals ( CLAIR ) trial was a r and omised , open-label , blinded-endpoint trial . Between Oct 28 , 2003 , and Nov 19 , 2008 , patients with acute ischaemic stroke or transient ischaemic attack who had symptomatic large artery stenosis in the cerebral or carotid arteries and in whom microembolic signals were present on transcranial doppler were r and omly assigned within 7 days of symptom onset to receive clopidogrel ( 300 mg for the first day , then 75 mg daily ) plus aspirin ( 75 - 160 mg daily ) or aspirin alone ( 75 - 160 mg daily ) for 7 days . Patients were r and omly assigned in blocks of four or six by use of a r and omisation website . Monitoring of microembolic signals on transcranial doppler was done on days 2 and 7 . The primary endpoint was the proportion of patients who had microembolic signals on day 2 . Analysis was by modified intention to treat . All analyses were done by an investigator masked to both patient identity and the day the recording was taken . This trial is registered with the Centre for Clinical Trials , Chinese University of Hong Kong , number CUHK_CCT00164 . FINDINGS 100 patients were r and omly assigned to clopidogrel plus aspirin ( n=47 ) or aspirin monotherapy ( n=53 ) . 93 of 100 patients had symptomatic intracranial stenosis in either the intracranial internal carotid artery or the middle cerebral artery : 45 of 46 in the dual therapy group and 48 of 52 in the monotherapy group . At day 2 , 14 of 45 patients in the dual therapy group and 27 of 50 patients in the monotherapy group for whom data were available had at least one microembolic signal on transcranial doppler ( relative risk reduction 42.4 % , 95 % CI 4.6 - 65.2 ; p=0.025 ) . Adverse events were similar in the two groups . No patients had intracranial or severe systemic haemorrhage , but two patients in the dual therapy group had minor haemorrhages . INTERPRETATION Combination therapy with clopidogrel and aspirin is more effective than aspirin alone in reducing microembolic signals in patients with predominantly intracranial symptomatic stenosis . Clinical trials are now warranted to investigate whether this combination treatment also results in a reduction in stroke incidence Background — Evidence for efficacy of dual antiplatelet therapy in stroke is limited . Symptomatic carotid stenosis patients are at high risk of early recurrent stroke . In this group , asymptomatic microembolic signals ( MES ) , detected by transcranial Doppler ultrasound ( TCD ) , are markers of future stroke and transient ischemic attack ( TIA ) risk . They offer a surrogate marker to evaluate antiplatelet therapy , but no multicenter study has evaluated the feasibility of this approach . Methods and Results —Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis ( CARESS ) is a r and omized , double-blind study in subjects with recently symptomatic ≥50 % carotid stenosis . Patients were screened with TCD , and if MES were detected , they were r and omized to clopidogrel and aspirin or aspirin monotherapy . Repeated TCD recordings were made on days 2 and 7 . MES were detected in 110 of 230 patients by online analysis at baseline , of whom 107 were r and omized . Intention-to-treat analysis revealed a significant reduction in the primary end point : 43.8 % of dual-therapy patients were MES positive on day 7 , as compared with 72.7 % of monotherapy patients ( relative risk reduction 39.8 % ; 95 % CI , 13.8 to 58.0 ; P=0.0046 ) . The secondary end point of MES frequency per hour was reduced ( compared with baseline ) by 61.4 % ( 95 % CI , 31.6 to 78.2 ; P=0.0013 ) in the dual-therapy group at day 7 and by 61.6 % ( 95 % CI , 34.9 to 77.4 ; P=0.0005 ) on day 2 . There were 4 recurrent strokes and 7 TIAs in the monotherapy group versus no stroke and 4 TIAs in the dual-therapy group that were treatment emergent and ipsilateral to the qualifying carotid stenosis ; 2 additional ipsilateral TIAs occurred before treatment started . MES frequency was greater in the 17 patients with recurrent ipsilateral events compared with the 90 without ( mean±SD : 24.4±27.7 versus 8.9±11.5 per hour ; P=0.0003 ) . Conclusions —In patients with recently symptomatic carotid stenosis , combination therapy with clopidogrel and aspirin is more effective than aspirin alone in reducing asymptomatic embolization . Doppler MES detection is a feasible method to evaluate the efficacy of antiplatelet therapy in multicenter studies Background : Little information is available about public knowledge of TIA and prevalence of a TIA diagnosis . Methods : The National Stroke Association sponsored a telephone survey by single-stage r and  om-digit dialing of noninstitutionalized US residents ≥18 years old , which was conducted in 1999 . Demographic characteristics of participants were compared to the US population to produce weights for projections . Independent predictors of knowledge and diagnosis of TIA were determined by including all demographic characteristics in logistic regression models . Results : Among 10,112 participants , 2.3 % reported having been told by a physician that they had a TIA . Older age , lower income , and fewer years of education were independently associated with a diagnosis of TIA . Of those with TIA , only 64 % saw a physician within 24 hours of the event . A physician diagnosis of stroke was reported by 2.3 % of participants , of whom 19 % recalled having had a TIA before the stroke . An additional 3.2 % of participants recalled symptoms consistent with TIA but did not seek medical attention . Only 8.2 % correctly related the definition of TIA and 8.6 % could identify a typical symptom . Men , nonwhites , and those with lower income and fewer years of education were less likely to be knowledgeable about TIA . Conclusions : An estimated 4.9 million people in the US report a diagnosis of TIA , and many more recall symptoms consistent with TIA but do not seek medical attention . Reducing stroke risk after TIA could have substantial impact on public health but will require public education about the importance of having stroke symptoms evaluated , even if they resolve BACKGROUND Evidence is available on the effectiveness and costs of treatments to reduce stroke risk in long-term secondary prevention . However , there are few data on the costs and outcomes of urgent assessment and treatment after the onset of transient ischaemic attack ( TIA ) or minor stroke . The Early use of eXisting PREventive Strategies for Stroke ( EXPRESS ) study showed that urgent assessment and treatment reduced the 90-day risk of recurrent stroke by about 80 % . We now report the effect of the EXPRESS intervention on admissions to hospital , costs , and disability . METHODS EXPRESS was a prospect i ve population -based before ( phase 1 : April 1 , 2002 , to Sept 30 , 2004 ) versus after ( phase 2 : Oct 1 , 2004 , to March 31 , 2007 ) study of the effect of early assessment and treatment of TIA or minor stroke on the risk of early recurrent stroke . This report assesses the effect of the introduction of the phase 2 clinic on admissions to hospital within 90 days , hospital bed-days , hospital costs , and 6-month new disability ( progression from no disability before event [ modified Rankin scale score < or = 2 points ] to disability at 6 months [ modified Rankin scale score > 2 points ] 
    Output:
    
Therefore , the treatment with Clop + ASA seems safe as well as effective for decreasing stroke recurrence .
In addition , this is related to a statistically insignificant trend in increasing vascular mortalities , MI , and primary hemorrhagic events .