What is the recommended treatment with Aspirin (acetylsalicylic acid) and Plavix (clopidogrel) after a cerebrovascular accident (CVA)?

Antiplatelet Therapy After Cerebrovascular Accident (CVA)

For patients who have experienced an ischemic stroke or transient ischemic attack (TIA), short-term dual antiplatelet therapy with aspirin plus clopidogrel for up to 21 days followed by long-term single antiplatelet therapy is recommended to reduce the risk of recurrent stroke and other vascular events. 1, 2

Initial Management After Ischemic Stroke/TIA

Acute Phase (First 21 days)

• Dual antiplatelet therapy (DAPT):
  • Aspirin 75-100 mg daily PLUS
  • Clopidogrel 75 mg daily (with initial loading dose of 600 mg) 1
  • Duration: 21 days from symptom onset
  • This combination reduces risk of recurrent ischemic events by 25% compared to aspirin alone during this high-risk period 1, 2
  • Caution: DAPT increases major bleeding risk (0.9% vs 0.4% with aspirin alone) 1

Long-term Secondary Prevention

• Single antiplatelet therapy after the initial 21-day period:
  • First choice: Clopidogrel 75 mg daily as monotherapy 3
  • Alternative: Aspirin 75-100 mg daily 3
  • Alternative: Combination of aspirin (50 mg) plus extended-release dipyridamole (200 mg twice daily) 3

Treatment Selection Based on Stroke Etiology

Non-cardioembolic Stroke/TIA

• Initial DAPT for 21 days, then:
• Clopidogrel 75 mg daily is preferred over aspirin alone (reduces risk by more than 20% compared to aspirin) 3, 4
• Aspirin 75-100 mg daily if clopidogrel is contraindicated 3
• Aspirin plus extended-release dipyridamole is a reasonable alternative 3

Cardioembolic Stroke/TIA

• For patients with atrial fibrillation:
  • Long-term oral anticoagulation is recommended 3
  • If oral anticoagulation is contraindicated: Aspirin 325 mg daily or clopidogrel 75 mg daily 3
• For patients with mechanical heart valves:
  • Oral anticoagulation plus aspirin (81 mg/day) 3

Important Clinical Considerations

Bleeding Risk Management

• Monitor for signs of bleeding, especially gastrointestinal and intracranial
• Consider adding a proton pump inhibitor (PPI) when using DAPT to reduce GI bleeding risk 3
• Avoid omeprazole or esomeprazole with clopidogrel due to potential interaction 5
• Consider pantoprazole or lansoprazole if PPI needed 5

Medication Adherence

• Emphasize the importance of consistent medication use
• Warn patients not to discontinue antiplatelet therapy without consulting their physician 5
• Inform patients they will bruise more easily and bleeding will take longer to stop 5

Special Situations

• For patients requiring surgery or dental procedures:
  • Inform healthcare providers about antiplatelet therapy 5
  • Procedures may need to be delayed if possible during initial DAPT period
• For patients with prior coronary stenting:
  • Management may require specialized approach with cardiology consultation 3

Evidence Summary

The POINT trial demonstrated that short-term dual antiplatelet therapy (≤1 month) significantly reduces the risk of recurrent stroke (RR 0.53,95% CI 0.37-0.78) without significantly increasing major bleeding compared to aspirin alone 1, 2. However, longer-term DAPT (>3 months) increases bleeding risk without providing additional benefit 2.

The CHARISMA trial showed no benefit for long-term combined use of aspirin and clopidogrel for stroke prevention in patients with prior history of ischemic stroke 3.

For long-term management, clopidogrel monotherapy appears to be more effective than aspirin alone in preventing recurrent vascular events in patients with recent stroke 3, 4.

Remember that antiplatelet therapy should be maintained indefinitely for secondary stroke prevention unless contraindicated.