From the Guidelines
The treatment for a 60-year-old man with a stroke requires immediate medical attention at a hospital, with a focus on reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, 1, published in 2020, recommends that if the stroke is ischemic (caused by a blood clot), treatment may include intravenous thrombolysis with tissue plasminogen activator (tPA) if administered within 4.5 hours of symptom onset, at a dose of 0.9 mg/kg with a maximum of 90 mg (10% given as bolus, remainder over 60 minutes). Some key points to consider in the treatment of stroke include:
- Mechanical thrombectomy may be performed within 24 hours for large vessel occlusions, as recommended by 1.
- Following acute management, the patient should receive antiplatelet therapy, typically aspirin 81-325 mg daily, often combined with clopidogrel 75 mg daily for 21 days in high-risk patients, then continued on aspirin alone, as suggested by 1 and 1.
- A statin like atorvastatin 40-80 mg daily is recommended regardless of baseline cholesterol levels, as stated in 1.
- Blood pressure management targets <140/90 mmHg using medications such as ACE inhibitors or ARBs, as recommended by 1 and 1.
- For hemorrhagic strokes, treatment focuses on controlling blood pressure, reversing anticoagulation if applicable, and possible surgical intervention, as suggested by 1 and 1.
- Rehabilitation including physical, occupational, and speech therapy should begin as soon as the patient is medically stable, as recommended by 1 and 1.
- Secondary prevention includes lifestyle modifications such as a Mediterranean diet, regular exercise, smoking cessation, and moderate alcohol consumption if the patient drinks, as suggested by 1 and 1.
From the FDA Drug Label
The CAPRIE trial was a 19,185-patient, 304-center, international, randomized, double-blind, parallel-group study comparing clopidogrel (75 mg daily) to aspirin (325 mg daily) To be eligible to enroll, patients had to have: 1) recent history of myocardial infarction (within 35 days); 2) recent histories of ischemic stroke (within 6 months) with at least a week of residual neurological signs; and/or 3) established peripheral arterial disease (PAD). The trial’s primary outcome was the time to first occurrence of new ischemic stroke (fatal or not), new myocardial infarction (fatal or not), or other vascular death.
The treatment for a 60-year-old man with a stroke may include clopidogrel (75 mg daily), as shown in the CAPRIE trial 2. This trial demonstrated a lower incidence of outcome events, primarily myocardial infarction, with clopidogrel compared to aspirin.
- Key points:
- Clopidogrel was associated with a lower incidence of outcome events.
- The overall relative risk reduction was 8.7%, p=0.045.
- Similar results were obtained when all-cause mortality and all-cause strokes were counted instead of vascular mortality and ischemic strokes. However, it is essential to consult the patient's healthcare provider to determine the best course of treatment, as individual patient needs may vary.
From the Research
Treatment Options for a 60-Year-Old Man with Stroke
The treatment for a 60-year-old man with stroke depends on several factors, including the type and severity of the stroke. According to 3, management of acute ischemic stroke in the first hours is critical to patient outcomes. The following are some treatment options:
- Thrombolysis: This involves the use of medications to dissolve blood clots that are causing the stroke. As stated in 4, intravenous thrombolysis is a key treatment option for acute ischemic stroke.
- Endovascular therapy: This involves the use of mechanical devices to remove blood clots from the brain. As mentioned in 4, endovascular thrombectomy is a treatment option for patients with large areas of brain at risk but without large completed infarcts.
- Antiplatelet therapy: This involves the use of medications to prevent blood clots from forming. According to 5, combination antiplatelet therapy with clopidogrel and aspirin may reduce the rate of recurrent stroke during the first 3 months after a minor ischemic stroke or transient ischemic attack (TIA).
- Dual-antiplatelet therapy: This involves the use of two antiplatelet medications, such as aspirin and clopidogrel. As stated in 6, dual-antiplatelet therapy may be superior to alteplase for achieving a better functional outcome in patients with acute minor ischemic stroke.
Special Considerations for Older Adults
Older adults, such as a 60-year-old man, may require special consideration when it comes to stroke treatment. According to 7, acute, interventional, and preventative treatments have mostly been trialled in younger age groups, and therefore, the evidence for these treatments in older adults is limited. However, as stated in 7, the majority of people who suffer a stroke are older adults, and therefore, it is essential to consider their unique needs and circumstances when developing treatment plans.
Treatment Goals
The primary goal of stroke treatment is to restore blood flow to the brain and prevent further damage. According to 3, the key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. The treatment goals for a 60-year-old man with stroke may include:
- Restoring blood flow to the brain
- Preventing further damage to the brain
- Improving functional outcomes
- Reducing the risk of recurrent stroke
- Managing symptoms and complications, such as 4 mentions, management of patient physiologic parameters to minimize infarct volumes.