What medications should be prescribed after stabilization from a cerebrovascular accident (CVA)?

Medications to Prescribe After Stabilization from CVA

After stabilization from a cerebrovascular accident (CVA), patients should be prescribed antiplatelet therapy with aspirin (75-150 mg daily) plus clopidogrel (75 mg daily) for at least 9-12 months to reduce the risk of recurrent stroke and other cardiovascular events. 1

Antiplatelet Therapy

• Aspirin should be administered within 24-48 hours after stroke onset at a dose of 75-150 mg daily. For patients treated with IV thrombolysis, aspirin administration should generally be delayed until >24 hours 1
• Based on the CURE trial, clopidogrel 75 mg should be prescribed for at least 9-12 months in combination with a reduced dose of aspirin (75-100 mg) 1
• Antiplatelet therapy choice should consider the patient's risk of aspirin resistance, which affects approximately 25-30% of stroke patients and increases the risk of recurrent events 1
• In patients with documented aspirin resistance or those at higher risk (older, female, smokers), clopidogrel may be preferred as monotherapy 1

Anticoagulation Therapy

• For patients with atrial fibrillation or other cardioembolic sources, anticoagulation is recommended over antiplatelet therapy 1
• Rivaroxaban 20 mg daily (for CrCl ≥50 mL/min) or 15 mg daily (for CrCl 15-49 mL/min) can be used for stroke prevention in non-valvular atrial fibrillation 2
• Warfarin with target INR 2-3 is recommended for patients with mechanical heart valves or when direct oral anticoagulants are contraindicated 1
• For patients with cerebral venous sinus thrombosis, anticoagulation should be started immediately, even if intracranial hemorrhage is present 1

Blood Pressure Management

• Blood pressure should be maintained below 180/105 mmHg for at least the first 24 hours after acute reperfusion treatment 1
• Long-term blood pressure control should target <140/90 mmHg or <130/80 mmHg for diabetic patients 1
• Angiotensin-converting enzyme (ACE) inhibitors alone or in combination with a diuretic, or angiotensin receptor blockers (ARBs) are recommended for long-term blood pressure management 1
• For patients with resistant hypertension, consider adding calcium channel blockers or beta-blockers to the regimen 1

Lipid-Lowering Therapy

• High-intensity statin therapy should be initiated without delay in all patients after ischemic stroke, regardless of baseline LDL cholesterol levels 1
• Based on the MIRACL trial, atorvastatin 80 mg daily can be started within 63 hours after admission to reduce the risk of rehospitalization for recurrent angina 1
• Statins provide benefits beyond atherosclerosis regression, including plaque stabilization, improved endothelial function, and decreased inflammation 1
• Target LDL cholesterol should be <100 mg/dL for secondary prevention 1

Diabetes Management

• For patients with diabetes, fasting blood glucose levels should be maintained below 126 mg/dL (7 mmol/L) 1
• Management includes diet, regular exercise (at least three times weekly), and oral hypoglycemic agents or insulin as needed 1
• Blood glucose should be monitored and maintained between 6-10 mmol/L (108-180 mg/dL) during the acute phase 1

Seizure Management

• Antiseizure medications are only indicated for documented secondary seizures and not for primary prevention 1
• If the patient has had a seizure, loading with anticonvulsant agents (e.g., levetiracetam 1 g or phenytoin 20 mg/kg, max 2 g) should be undertaken before transfer 1

Lifestyle Modifications

• Smoking cessation should be strongly encouraged with counseling, nicotine replacement therapies, bupropion, or formal smoking cessation programs 1
• Weight reduction is recommended for patients with BMI >25, especially those with BMI >30 1
• Regular physical activity (at least 10 minutes of exercise 3-4 times weekly) is recommended 1
• Reduced salt intake is generally advised 1

Special Considerations

• Elderly patients (>65 years) have nearly twice the frequency of recurrent strokes compared to coronary heart disease events during the first year after initial stroke 3
• Patients with a CHADS₂ score ≥2 or history of previous stroke are at significantly higher risk for recurrent cerebrovascular events and may require more aggressive antithrombotic therapy 4
• Patients with cardioembolic strokes have the highest mortality and recurrence rates, while lacunar strokes have the lowest 3

Common Pitfalls and Caveats

• Underutilization of preventive therapies is common, particularly among older patients, women, and those with lower incomes 3
• Aspirin resistance may develop over time, with up to 33% of initially aspirin-sensitive patients unable to completely inhibit platelet aggregation at 33 months 1
• Avoid high-dose glucocorticoids after severe traumatic brain injury as they increase mortality 5
• Hormone replacement therapy may be harmful for secondary stroke prevention in postmenopausal women 1
• When using statins, monitor for potential side effects including myopathy (5-10% of patients) and elevated liver enzymes 1

By implementing these evidence-based medication strategies after CVA stabilization, the risk of recurrent stroke and other cardiovascular events can be significantly reduced, improving long-term outcomes for patients.