What medications are recommended after an ischemic stroke?

From the Guidelines

After an ischemic stroke, antiplatelet therapy with aspirin (81-325 mg daily) or clopidogrel (75 mg daily) is recommended to prevent recurrence and manage complications. The selection of an antiplatelet agent should be individualized based on patient risk factor profiles, cost, tolerance, and other clinical characteristics 1. According to the most recent guidelines, antiplatelet agents are recommended for secondary stroke prevention in patients with non-cardioembolic ischemic events who do not require oral anticoagulation, including aspirin 81–325 mg daily, clopidogrel 75 mg daily, or aspirin + dipyridamole 25/200 mg daily 1.

Key Considerations

• Aspirin (81-325 mg daily) is often started within 24-48 hours of stroke onset and continued indefinitely 1.
• For higher-risk patients, dual antiplatelet therapy with aspirin plus clopidogrel (75 mg daily) may be used for the first 21 days 1.
• In patients with minor ischemic stroke or high-risk TIA, DAPT with aspirin and clopidogrel should be initiated as early as possible, ideally within 12–24 h of symptoms onset, after an intracranial hemorrhage is excluded on neuroimaging studies 1.
• The addition of aspirin to clopidogrel increases the risk of hemorrhage and is not recommended for routine secondary prevention after ischemic stroke or TIA 1.

Additional Recommendations

• Statins are prescribed regardless of baseline cholesterol levels, typically high-intensity statins like atorvastatin (40-80 mg daily) or rosuvastatin (20-40 mg daily) 1.
• Blood pressure management is crucial, with a target below 130/80 mmHg using medications like ACE inhibitors (lisinopril 10-40 mg daily), ARBs, calcium channel blockers, or thiazide diuretics 1.
• For diabetic patients, tight glucose control is important 1.

It is essential to note that the most recent and highest quality study 1 provides the most up-to-date recommendations for medication use after an ischemic stroke, and these guidelines should be followed to prioritize morbidity, mortality, and quality of life as the outcome.

From the Research

Medication Recommendations after Ischemic Stroke

Medications recommended after an ischemic stroke include antiplatelet therapy, which has been shown to reduce the risk of recurrent stroke and improve outcomes.

• Aspirin is a commonly used antiplatelet agent, with studies such as 2 demonstrating its safety and effectiveness in acute ischemic stroke, reducing early recurrent strokes and improving long-term functional outcomes.
• The dose of aspirin required for rapid inhibition of thromboxane biosynthesis is around 160-300 mg, which can be administered orally or per rectum as a suppository if the patient cannot swallow safely 2.
• Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin may provide greater protection against subsequent stroke than monotherapy, with studies such as 3 showing significantly lower rates of any stroke and ischemic stroke during follow-up periods.
• However, DAPT is associated with increased risks of intracranial bleeding and major bleeding, especially with long-term follow-up, highlighting the need for careful consideration of the benefits and risks of DAPT in individual patients 3, 4.

Dual Antiplatelet Therapy

Dual antiplatelet therapy with clopidogrel and aspirin has been shown to be effective in reducing the risk of recurrent stroke, particularly when initiated early after an acute mild stroke.

• Studies such as 3 and 4 have demonstrated the benefits of DAPT in reducing the risk of new stroke, with hazard ratios of 0.80 and 0.79, respectively.
• However, the optimal duration of DAPT is unclear, with some studies suggesting that short-duration DAPT (≤ 1 month) may be associated with less bleeding and greater reduction of recurrent strokes compared to longer DAPT 3.
• Other antiplatelet agents, such as ticagrelor, have also been shown to be effective in reducing the risk of recurrent stroke, although the evidence is less extensive compared to clopidogrel and aspirin 5.

Clinical Considerations

The choice of medication and duration of treatment should be individualized based on the patient's clinical characteristics, medical history, and risk factors for bleeding and recurrent stroke.

• Patients who experience an ischemic stroke or transient ischemic attack while on aspirin monotherapy may benefit from the addition of or a switch to another antiplatelet agent, especially in the first days after the index event 5.
• The risk of bleeding should be carefully considered, particularly in patients with a history of bleeding or those taking other medications that increase the risk of bleeding 3, 4.
• Further research is needed to determine the optimal antiplatelet regimen and duration of treatment for patients with ischemic stroke, taking into account the benefits and risks of different treatment strategies 3, 4.