From the Guidelines
Minor stroke in the emergency department requires prompt assessment and treatment to prevent progression and recurrence, with the most recent and highest quality study recommending antiplatelet therapy for secondary prevention of recurrent stroke 1. The initial management includes immediate neuroimaging (CT or MRI) to rule out hemorrhage.
- For most patients, antiplatelet therapy is recommended, with options including acetylsalicylic acid (80–325 mg daily), combined acetylsalicylic acid (25 mg) and extended-release dipyridamole (25 mg/200 mg twice daily), or clopidogrel (75 mg daily) 1.
- Short-term concurrent use of acetylsalicylic acid and clopidogrel (up to 21 days) may be protective following minor stroke or transient ischemic attack, but longer-term use is not recommended due to an increased risk of bleeding and mortality 1. Key considerations in management include:
- Blood pressure management, targeting <185/110 mmHg initially, with gradual reduction to <140/90 mmHg over days to weeks.
- Statin therapy, typically high-intensity such as atorvastatin 40-80 mg daily.
- Monitoring for neurological deterioration for at least 24 hours, with consideration for admission depending on symptom stability, comorbidities, and social support.
- Additional workup, including cardiac monitoring for atrial fibrillation, carotid imaging if appropriate, and evaluation for modifiable risk factors such as diabetes and smoking.
- Early mobilization and rehabilitation assessment should be initiated, as this comprehensive approach addresses the immediate threat while establishing secondary prevention to reduce the risk of recurrent stroke. In patients with a history of ischemic stroke or TIA and atrial fibrillation, oral anticoagulation is recommended over no antithrombotic therapy, aspirin, or combination therapy with aspirin and clopidogrel 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Minor Stroke
- Dual antiplatelet therapy with clopidogrel and aspirin has been shown to be effective in preventing recurrent strokes after minor ischemic stroke or transient ischemic attack (TIA) 2, 3, 4.
- The combination of clopidogrel and aspirin offers balanced efficacy and safety, positioning it as a potentially optimal treatment for minor stroke 2.
- Ticagrelor and aspirin is another dual antiplatelet therapy regimen that has been compared to clopidogrel and aspirin, with no statistically significant difference found between the two regimens for the primary outcome of recurrent stroke or death 5.
Efficacy and Safety Outcomes
- Aspirin plus clopidogrel was more strongly associated with primary outcome (mRS 0-1) than aspirin alone and rt-PA 2.
- Aspirin plus clopidogrel also had a lower risk of symptomatic intracranial hemorrhage (sICH) than rt-PA and tenecteplase 2.
- Dual antiplatelet therapy with clopidogrel and aspirin reduced the risk of major ischemic events at 90 days compared with aspirin alone, mainly within the first 21 days 4.
- Major hemorrhages were more frequent in the clopidogrel-aspirin group, but the difference was nonsignificant 4.
Comparison of Dual Antiplatelet Therapy Regimens
- Both clopidogrel and aspirin, and ticagrelor and aspirin were superior to aspirin alone in the prevention of recurrent stroke and death 5.
- There was no statistically significant difference between clopidogrel and aspirin compared with ticagrelor and aspirin for the primary outcome 5.
- Both dual antiplatelet therapy regimens had higher rates of major hemorrhage than aspirin alone 5.