Is Plavix (clopidogrel) started after an ischemic stroke?

Antiplatelet Therapy After Ischemic Stroke

Aspirin 325 mg should be started within 24-48 hours after ischemic stroke onset as the primary antiplatelet agent, while clopidogrel (Plavix) is not recommended for routine acute stroke management but is an acceptable option for long-term secondary prevention. 1

Acute Management (First 24-48 Hours)

First-Line Therapy:

• Aspirin 325 mg should be administered within 24-48 hours of stroke onset (Class I, Level of Evidence A) 1
• Aspirin provides a modest but statistically significant benefit in reducing mortality and morbidity, primarily by preventing early recurrent stroke 1
• Do NOT administer aspirin within 24 hours of thrombolytic therapy (rtPA) 1

NOT Recommended in Acute Phase:

• Clopidogrel alone or in combination with aspirin is NOT recommended for treatment of acute ischemic stroke (Class III, Level of Evidence C) 1
• The administration of aspirin as adjunctive therapy within 24 hours of thrombolytic therapy is not recommended (Class III, Level of Evidence A) 1

Transition to Long-Term Secondary Prevention

After the acute phase (typically after 24-48 hours), the focus shifts to long-term secondary prevention:

Acceptable Options for Long-Term Prevention:

1. Aspirin (50-325 mg daily) monotherapy
2. Clopidogrel (75 mg daily) monotherapy
3. Aspirin (25 mg) plus extended-release dipyridamole (200 mg) twice daily 1

Selection Considerations:

• All three options above are considered acceptable first-line therapies for long-term secondary prevention
• The selection should be based on patient-specific factors including risk profile, medication tolerance, and cost 1

Important Clinical Considerations

Dual Antiplatelet Therapy (DAPT):

• Recent evidence suggests short-duration DAPT (≤1 month) with clopidogrel plus aspirin started early after stroke may reduce recurrent stroke risk compared to monotherapy 2, 3
• However, long-term DAPT increases bleeding risk without additional benefit in stroke prevention 4
• The 2021 AHA/ASA guidelines acknowledge emerging evidence for short-term DAPT but maintain that monotherapy remains standard for most patients 1

Bleeding Risk:

• Dual antiplatelet therapy increases risk of major bleeding (RR 1.90) and intracranial bleeding (RR 1.55) compared to monotherapy 2
• The risk of bleeding increases with longer duration of dual therapy 2, 4

Common Pitfalls to Avoid:

1. Delaying aspirin administration beyond 48 hours after stroke onset in eligible patients
2. Administering clopidogrel alone in the acute phase (first 24-48 hours)
3. Starting antiplatelet therapy before ruling out hemorrhagic stroke
4. Administering aspirin within 24 hours of thrombolytic therapy
5. Continuing dual antiplatelet therapy beyond the recommended short-term period (typically 21-90 days) without specific indications

Special Considerations

• For patients allergic to aspirin, clopidogrel is a reasonable alternative 1
• For patients who have an ischemic stroke while taking aspirin, there is no evidence that increasing the dose provides additional benefit 1
• Initiation of clopidogrel at a standard dose of 75 mg does not produce maximal platelet inhibition for approximately 5 days, which limits its effectiveness in the acute setting 1

The evidence clearly supports aspirin as the primary antiplatelet agent in the acute phase of ischemic stroke, with clopidogrel being reserved for long-term secondary prevention rather than acute management.