Antiplatelet Therapy for Patients with New Lacunar Infarcts
Antiplatelet therapy is recommended for patients with new lacunar infarcts to reduce the risk of recurrent stroke. 1, 2
Evidence for Antiplatelet Therapy in Lacunar Stroke
- Antiplatelet therapy is the mainstay of pharmacological management in patients with cerebrovascular disease, including lacunar infarcts 3
- Single antiplatelet therapy has been shown to significantly reduce the risk of recurrent stroke in patients with lacunar infarcts compared to placebo 4
- Aspirin has demonstrated efficacy in reducing stroke recurrence risk in patients with lacunar stroke in long-term follow-up studies 1
- Antiplatelet drugs, along with blood pressure control, statins, and lifestyle modifications, are key elements in secondary prevention after lacunar stroke 2
Choice of Antiplatelet Agent
- Any single antiplatelet agent (aspirin, clopidogrel, or others) is appropriate for secondary prevention after lacunar stroke 4
- Aspirin (75-100 mg daily) is recommended for long-term prevention of serious vascular events in high-risk patients 3
- Clopidogrel 75 mg daily is an alternative antiplatelet option for patients with non-cardioembolic ischemic events 3
Important Considerations
Dual antiplatelet therapy (DAPT) is not recommended for long-term secondary prevention after lacunar stroke 4
- The SPS3 trial showed that adding clopidogrel to aspirin did not significantly reduce recurrent stroke risk but significantly increased bleeding risk and mortality in patients with recent lacunar strokes 5
- The risk of major hemorrhage was almost doubled with dual antiplatelet therapy compared to aspirin alone (2.1% vs 1.1% per year) 5
For patients with minor ischemic stroke (NIHSS ≤3) or high-risk TIA, short-term DAPT (21 days) followed by long-term single antiplatelet therapy may be considered 3
Monitoring and Follow-up
- Lacunar infarcts should be regarded as potentially severe conditions rather than benign disorders, requiring adequate management and follow-up 2
- Despite favorable short-term prognosis, lacunar infarcts are associated with increased risk of death, stroke recurrence, and dementia in the mid and long term 2, 6
- Careful blood pressure control is essential alongside antiplatelet therapy for optimal secondary prevention 2, 6
Special Situations
- In patients who are already on anticoagulation for atrial fibrillation and develop a lacunar infarct, the decision to add an antiplatelet agent should be individualized based on thrombotic and bleeding risks 3
- For patients with COVID-19 and stable peripheral artery disease who develop lacunar infarcts, antiplatelet therapy should be continued if concurrent prophylactic-dose anticoagulation is being given 3
In conclusion, antiplatelet therapy is indicated for patients with new lacunar infarcts, with single antiplatelet therapy (rather than dual therapy) being the preferred long-term approach to reduce recurrent stroke risk while minimizing bleeding complications.