Objective:To analyze the efficacy and safety of dual antiplatelet therapy guided by thromboelastography (TEG).Methods:One hundred and nine patients with ischemic cerebrovascular diseases, admitted to and accepted dual antiplatelet therapy in our hospital from August 2020 to April 2021, were enrolled in this study. TEG test was completed 3-5 d after treatment, and clopidogrel gene test was completed during hospitalization. According to the results of adenosine diphosphate (ADP) inhibition rate in TEG, they were divided into high-efficiency group, moderate efficiency group and low efficiency group. No medication change was recommended for patients in the high-efficiency group, but medication changes were recommended for patients in the moderate efficiency group and low efficiency group; differences of National Institutes of Health Stroke Scale (NIHSS) scores, efficacies and safety were recorded in these 3 groups after drug adjustment.Results:The proportion of patients with coronary heart disease in moderate efficiency group was statistically higher than that in high-efficiency group and low efficiency group ( P<0.05). Six patients in the high-efficiency group switched to use aspirin and cilostazol; 28 in the moderate efficiency group and 14 patients in the low efficiency group were disinclined to change their medications and continued to use aspirin+clopidogrel. In patients from the high-efficiency group, the overall incidence of new stroke and in-stent restenosis in patients without changing medications (1/39) was lower than that in patients with changing medications (1/6); in patients from the moderate efficiency group, that in patients without changing medications (6/28) was higher than that in patients with changing medications (1/9); in patients from the low efficiency group, that in patients without changing medications (3/14) was higher than that in patients with changing medications (0/13). In patients with slow metabolism from high-efficiency group, the overall incidence of new stroke and in-stent restenosis in patients without changing medications (2/3) was higher than that in patients with changing medications (1/2). Conclusions:Dual antiplatelet therapy guided by TEG can reduce clinical adverse events without increasing the risk of bleeding. For patients with ADP inhibition rate>70% and clopidogrel genotype (slow metabolism), clopidogrel replacement can further improve efficacy.