What is the standard medication regimen for patients post acute stroke?

Standard Medication Regimen Post Acute Stroke

For patients with acute ischemic stroke, the standard medication regimen should include aspirin 160-325 mg within 24-48 hours of stroke onset, followed by long-term antiplatelet therapy for secondary prevention. 1

Initial Antiplatelet Therapy

For Ischemic Stroke:

• Aspirin (160-300 mg) should be given as soon as possible after the onset of stroke symptoms (within 48 hours) once CT/MRI scan has excluded hemorrhage 1, 2
• For patients treated with IV thrombolysis (rtPA), aspirin administration should be delayed until 24 hours after thrombolysis and after a repeat scan has excluded hemorrhage 2
• Initial aspirin therapy reduces mortality by approximately 14% and decreases early recurrent ischemic strokes without major risk of hemorrhagic complications 3, 4

For Minor Stroke or High-Risk TIA:

• Consider dual antiplatelet therapy with aspirin plus clopidogrel for 21-30 days 5, 2
  • Loading dose: Aspirin 160-325 mg plus clopidogrel 300-600 mg 5
  • Maintenance: Aspirin 75-100 mg daily plus clopidogrel 75 mg daily 5, 6

Long-Term Secondary Prevention

For Non-Cardioembolic Stroke:

• Aspirin (75-162 mg daily) is recommended for long-term maintenance therapy 2
• Alternative options if aspirin is not tolerated:
  • Clopidogrel 75 mg daily 2
  • For patients with stroke related to 50%-99% intracranial stenosis, a higher dose of aspirin (325 mg/day) is specifically recommended 2

Blood Pressure Management

• During the first 24 hours after acute reperfusion treatment, blood pressure should be maintained below 180/105 mmHg 1
• For patients with extremely high blood pressure (>220/120 mmHg), cautious reduction (by no more than 10-20%) is recommended 1
• Recommended medications for BP control during and after rtPA:
  • Labetalol 10-20 mg IV over 1-2 minutes (may repeat once) 1
  • Nicardipine 5 mg/h IV, titrated up by 2.5 mg/h every 5-15 minutes (maximum 15 mg/h) 1

Additional Management Considerations

Venous Thromboembolism Prophylaxis:

• Intermittent pneumatic compression devices for patients with limited mobility 1
• Early mobilization and adequate hydration should be encouraged 1

Temperature Management:

• Monitor temperature every 4 hours for the first 48 hours 1
• For temperature >37.5°C, initiate temperature-reducing measures and investigate possible infection 1

Seizure Management:

• New-onset seizures should be treated with appropriate short-acting medications (e.g., lorazepam IV) if not self-limiting 1
• Prophylactic use of anticonvulsant medications is not recommended and may harm neurological recovery 1

Special Considerations

For Intracerebral Hemorrhage (ICH):

• Anticoagulation should be reversed immediately 1
• For vitamin K antagonist-associated ICH with INR ≥2.0,4-factor prothrombin complex concentrate is recommended over fresh-frozen plasma 1
• For direct oral anticoagulant-related ICH, specific reversal agents should be used (idarucizumab for dabigatran; andexanet alpha or 4F-PCC for factor Xa inhibitors) 1

For Cerebral Venous Sinus Thrombosis:

• Anticoagulation should be started immediately after diagnosis, even if intracranial hemorrhage is present 1
• IV heparin or subcutaneous low molecular weight heparin can be used 1

Monitoring Requirements

• Cardiac monitoring for at least the first 24 hours to screen for atrial fibrillation and other arrhythmias 1
• Blood pressure monitoring every 15 minutes for 2 hours from the start of rtPA therapy, then every 30 minutes for 6 hours, and then every hour for 16 hours 1

Common Pitfalls to Avoid

• Delaying aspirin administration in eligible patients (reduces efficacy in preventing early recurrent stroke) 3, 4
• Using antiplatelet agents as a substitute for other acute interventions like IV rtPA 1
• Administering aspirin within 24 hours of intravenous fibrinolysis (increases bleeding risk) 1
• Routine use of anticoagulation (e.g., intravenous unfractionated heparin) in unselected patients following ischemic stroke 1