Ischemic Stroke

Secondary Prevention ÎIn patients with a history of noncardioembolic ischemic stroke or TIA, the ACCP recommends long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended-release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (1-A), oral anticoagulants (1-B), the combination of clopidogrel plus aspirin (1-B), or triflusal (2-B). ÎOf the recommended antiplatelet regimens, the ACCP suggests clopidogrel or aspirin/extended release dipyridamole over aspirin (2-B) or cilostazol (2-C). Remark: With long-term use (> 5 years), the benefit of clopidogrel over aspirin in preventing major vascular events may be offset by a reduction in cancer-related mortality with regimens that contain aspirin. ÎIn patients with a history of ischemic stroke or TIA and atrial fibrillation (AF), including paroxysmal AF, the ACCP recommends oral anticoagulation over no antithrombotic therapy (1-A), aspirin (1-B), or combination therapy with aspirin and clopidogrel (1-B). ÎIn patients with a history of ischemic stroke or TIA and AF, including paroxysmal AF, the ACCP suggests oral anticoagulation with dabigatran* 150 mg bid over adjusted-dose vitamin K antagonist (VKA) therapy (target international normalized ration [INR] range 2.0-3.0) (2-B). * Dabigatran is excreted primarily by the kidney. It has not been studied and is contraindicated in patients with severe renal impairment (estimated creatinine clearance (ClCr ) of 30 mL/min or less). ÎIn patients with a history of ischemic stroke or TIA and AF, including paroxysmal AF, who are unsuitable for or choose not to take an oral anticoagulant (for reasons other than concerns about major bleeding), the ACCP recommends combination therapy with aspirin and clopidogrel over aspirin (1-B). Remark: Patients should be treated (ie, bridged) with aspirin until anticoagulation has reached a therapeutic level. ÎOral anticoagulation should generally be initiated within 1 to 2 weeks after stroke onset. Earlier anticoagulation can be considered for patients at low risk of bleeding complications (eg, those with a small infarct burden and no evidence of hemorrhage on brain imaging). Delaying anticoagulation should be considered for patients at high risk of hemorrhagic complications (eg, those with extensive infarct burden or evidence of significant hemorrhagic transformation on brain imaging). ÎIn patients with a history of a symptomatic primary ICH, the ACCP suggests NOT using long-term antithrombotic therapy for the prevention of ischemic stroke (2-C). Remark: Patients who might benefit from antithrombotic therapy are those at relatively low risk of recurrent ICH (eg, with deep hemorrhages) and relatively high risk (> 7% per year) of thromboembolic events (eg, with mechanical heart valves or CHADS2 ≥ 4 points). score

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