What are the indications for Aspirin (acetylsalicylic acid) and Plavix (clopidogrel) in acute Cerebrovascular Accident (CVA)?

From the Guidelines

Aspirin and Plavix (clopidogrel) are indicated for acute ischemic stroke but contraindicated in hemorrhagic stroke, with aspirin started within 24 hours at a dose of 160-325mg initially, followed by 81mg daily for secondary prevention, and clopidogrel used in combination with aspirin as dual antiplatelet therapy (DAPT) for high-risk patients, particularly those with minor stroke or high-risk TIA, at a loading dose of 300-600mg followed by 75mg daily 1.

Indications for Aspirin and Plavix in Acute CVA

The primary indications for aspirin and Plavix (clopidogrel) in acute cerebrovascular accident (CVA) are:

• Acute ischemic stroke
• Transient ischemic attack (TIA)
• Secondary prevention of recurrent stroke

Dosage and Administration

The recommended dosage and administration for aspirin and Plavix (clopidogrel) are:

• Aspirin: 160-325mg initially, followed by 81mg daily for secondary prevention 1
• Clopidogrel: loading dose of 300-600mg, followed by 75mg daily 1

Dual Antiplatelet Therapy (DAPT)

DAPT with aspirin and clopidogrel is recommended for high-risk patients, particularly those with minor stroke or high-risk TIA, for a duration of 21-30 days, followed by antiplatelet monotherapy 1.

Important Considerations

Before starting these medications, hemorrhagic stroke must be ruled out with brain imaging, and bleeding risk should be assessed 1. Patients should be monitored for bleeding complications, particularly gastrointestinal bleeding, and proton pump inhibitors may be considered for those at high risk of GI bleeding.

Evidence-Based Recommendations

The recommendations are based on the most recent and highest quality studies, including the Canadian Stroke Best Practice Recommendations for acute stroke management 1 and the guidelines for the early management of patients with acute ischemic stroke from the American Heart Association/American Stroke Association 1.

From the FDA Drug Label

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 CAPRIE trial enrolled a population that had recent MI, recent stroke, or PAD. The efficacy of clopidogrel relative to aspirin was heterogeneous across these subgroups (p=0. 043) The benefit was most apparent in patients who were enrolled because of peripheral arterial disease and less apparent in stroke patients In patients who were enrolled in the trial on the sole basis of a recent myocardial infarction, clopidogrel was not numerically superior to aspirin.

The indications for Aspirin and Plavix (clopidogrel) in acute Cerebrovascular Accident (CVA) are:

• Recent histories of ischemic stroke (within 6 months) with at least a week of residual neurological signs The use of clopidogrel is indicated for patients with:
• Recent myocardial infarction (within 35 days)
• Recent ischemic stroke (within 6 months)
• Established peripheral arterial disease (PAD) Aspirin is used in similar situations, but clopidogrel may be more beneficial in certain subgroups, such as those with PAD 2.

From the Research

Indications for Aspirin and Plavix in Acute CVA

The indications for Aspirin (acetylsalicylic acid) and Plavix (clopidogrel) in acute Cerebrovascular Accident (CVA) are as follows:

• Aspirin is indicated for the prevention of recurrent stroke in patients with acute ischemic stroke or transient ischemic attack (TIA) 3, 4
• Clopidogrel is indicated for the prevention of recurrent stroke in patients with acute ischemic stroke or TIA, and can be used in combination with aspirin for dual antiplatelet therapy (DAPT) 5, 6
• DAPT with clopidogrel and aspirin may provide greater protection against subsequent stroke than monotherapy, especially in the early acute phase 5
• However, the use of DAPT is associated with an increased risk of bleeding, particularly intracranial bleeding and major bleeding 5, 6, 7

Dosage and Duration

• The optimal dosage and duration of aspirin and clopidogrel therapy in acute CVA are not well established, but studies suggest that short-duration DAPT (≤ 1 month) may be more effective and safer than long-term DAPT 5
• Aspirin doses ranging from 75 to 150 mg daily are as effective as higher doses for long-term treatment, and doses < 75 mg daily may be less effective 4

Clinical Outcomes

• The use of aspirin and clopidogrel in acute CVA has been shown to reduce the risk of recurrent stroke, myocardial infarction, and vascular death 3, 4, 6
• However, the risk of bleeding, particularly intracranial bleeding and major bleeding, must be carefully weighed against the potential benefits of therapy 5, 6, 7
• Other clinical outcomes, such as recurrent TIA, myocardial infarction, vascular death, and any death, are essentially similar between DAPT and monotherapy 5