What are the follow-up recommendations for a 71-year-old female patient who recently suffered a stroke with left-sided weakness and sensory loss, and has a past medical history of Coronary Artery Disease and a previous small stroke?

From the Guidelines

For this 71-year-old female stroke patient with left-sided weakness, sensory loss, and history of CAD and previous stroke, I recommend a comprehensive follow-up plan prioritizing morbidity, mortality, and quality of life. The patient should be started on antiplatelet therapy, with aspirin 325mg daily recommended over oral anticoagulation for patients with ischemic stroke or TIA caused by moderate to high-grade intracranial atherosclerotic stenosis (50-99%) 1. A high-intensity statin such as atorvastatin 40-80mg daily should be initiated regardless of baseline cholesterol levels, with a target LDL-cholesterol of 1.8 mmol/L (70 mg/dL) 1. Blood pressure management is crucial, targeting a systolic blood pressure of <140 mmHg 1. The patient requires a cardiac workup including echocardiogram to evaluate for cardioembolic sources and carotid ultrasound to assess for stenosis. Physical therapy, occupational therapy, and speech therapy (if language deficits exist) should begin immediately and continue as an outpatient. Regular monitoring of neurological status is essential, with follow-up appointments at 1 week, 1 month, and 3 months post-discharge. Lifestyle modifications including Mediterranean diet, smoking cessation if applicable, limited alcohol intake, and at least moderate physical activity 1 are important. These recommendations aim to prevent recurrent stroke by addressing multiple risk factors, as this patient's history of CAD and previous stroke places her at significantly higher risk for additional cerebrovascular events.

Some key aspects of the follow-up plan include:

• Medication management: antiplatelet therapy, statins, and antihypertensives
• Cardiac workup: echocardiogram and carotid ultrasound
• Rehabilitation: physical, occupational, and speech therapy
• Lifestyle modifications: diet, exercise, smoking cessation, and limited alcohol intake
• Regular monitoring: follow-up appointments at 1 week, 1 month, and 3 months post-discharge

It is essential to note that the patient, family, and caregivers should be fully informed about, prepared for, and involved in all aspects of healthcare and safety needs 1. Additionally, aerobic exercise is important for all patients after stroke, regardless of specific rehabilitation needs 1. By prioritizing morbidity, mortality, and quality of life, this comprehensive follow-up plan aims to improve the patient's overall outcome and reduce the risk of recurrent stroke.

From the FDA Drug Label

1 INDICATIONS AND USAGE

1. 2 Recent MI, Recent Stroke, or Established Peripheral Arterial Disease In patients with established peripheral arterial disease or with a history of recent myocardial infarction (MI) or recent stroke clopidogrel tablets are indicated to reduce the rate of MI and stroke.

The patient should be administered clopidogrel in conjunction with aspirin to reduce the rate of myocardial infarction and stroke.

• The patient has a history of recent stroke and Coronary Artery Disease, which are indications for clopidogrel therapy.
• Follow-up recommendations should include monitoring for signs and symptoms of myocardial infarction and stroke, as well as regular assessment of the patient's mobility and sensory function 2.

From the Research

Follow-up Recommendations

The patient, a 71-year-old female, recently suffered a stroke with left-sided weakness and sensory loss, and has a past medical history of Coronary Artery Disease and a previous small stroke. Based on the available evidence, the following follow-up recommendations can be made:

• The patient should be considered for dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for a short period, typically 21-30 days, to reduce the risk of recurrent stroke 3, 4.
• The patient's bleeding risk should be assessed, and if it is high, a shorter duration of DAPT may be considered 5, 6.
• The patient should be monitored for both minor and major bleeding complications, including intracranial hemorrhage 3, 4.
• After the initial period of DAPT, the patient can be switched to single antiplatelet therapy (SAPT) with aspirin or clopidogrel for long-term secondary stroke prevention 4.
• The patient's risk of recurrent stroke should be assessed using a tool such as the Stroke Prognosis Instrument II (SPI-II) score, and the treatment plan should be tailored accordingly 7.

Considerations for Antiplatelet Therapy

• The choice of antiplatelet therapy should be based on the patient's individual risk factors, including bleeding risk, history of stroke or transient ischemic attack, and presence of coronary artery disease 5, 6.
• The patient should be educated on the importance of adherence to the prescribed antiplatelet regimen and the potential risks and benefits of therapy 4.
• Regular follow-up appointments should be scheduled to monitor the patient's response to therapy and adjust the treatment plan as needed 4, 7.