What is the best course of action for a patient with slow walking and slurred speech post-stroke, currently on aspirin (acetylsalicylic acid) and clopidogrel, to determine reversibility and adjust treatment?

Management of Post-Stroke Symptoms with Dual Antiplatelet Therapy

Antiplatelet Therapy Recommendations

For a patient with slow walking and slurred speech post-stroke who is currently on aspirin and clopidogrel, the dual antiplatelet therapy should be maintained for only 21-30 days after the initial stroke event, followed by transition to single antiplatelet therapy for long-term secondary prevention. 1, 2

The current evidence supports the following approach:

• Short-term dual antiplatelet therapy with aspirin and clopidogrel (up to 21-30 days) has shown benefit in reducing recurrent stroke risk without significantly increasing bleeding risk in the acute post-stroke period 1, 3
• Long-term dual therapy beyond 30 days is not recommended due to increased bleeding risk without additional benefit in stroke prevention 1
• After the initial 21-30 day period, patients should transition to monotherapy with either aspirin (75-100 mg daily), clopidogrel (75 mg daily), or combined aspirin/extended-release dipyridamole 1, 2

Assessment of Symptom Reversibility

To determine if the slow walking and slurred speech symptoms are reversible:

• These symptoms likely represent residual neurological deficits from the initial stroke rather than ongoing ischemia that would benefit from continued dual antiplatelet therapy 1
• Neurological recovery typically occurs within the first 3-6 months post-stroke, with most improvement happening in the first 30 days 2
• Rehabilitation therapy should be the primary approach for improving these functional deficits rather than extended dual antiplatelet therapy 1

Treatment Algorithm

1. Current status evaluation:

   • Determine how long the patient has been on dual antiplatelet therapy (aspirin + clopidogrel) 1
   • Assess for any signs of bleeding complications, which are more common with prolonged dual therapy 1, 4

2. If within 30 days of stroke:

   • Continue dual antiplatelet therapy to complete the recommended 21-30 day course 1, 3
   • Initiate rehabilitation therapy for motor and speech deficits 2

3. If beyond 30 days post-stroke:

   • Transition to monotherapy with either aspirin or clopidogrel 1, 2
   • Expert opinion suggests that if the stroke occurred while the patient was already on aspirin, switching to clopidogrel monotherapy may be reasonable 1

4. Rehabilitation focus:

   • Physical therapy for gait training to address slow walking 2
   • Speech therapy for dysarthria (slurred speech) 2

Important Considerations

• Dual antiplatelet therapy with aspirin and clopidogrel has been shown to reduce the risk of recurrent stroke by approximately 20-30% compared to aspirin alone in the short term (≤30 days) 3, 5
• However, long-term dual therapy significantly increases bleeding risk (RR = 1.81,95% CI = 1.65-1.99) without providing additional stroke prevention benefits 4
• The MATCH trial demonstrated that long-term combination therapy with clopidogrel plus aspirin showed no significant benefit over clopidogrel alone in reducing stroke recurrence but increased the risk of life-threatening bleeding by 1.3% 1
• Recent evidence from the INSPIRES trial supports the benefit of dual antiplatelet therapy when initiated within 72 hours after symptom onset 3

Monitoring and Follow-up

• Monitor for signs of bleeding while on dual antiplatelet therapy 1, 4
• Assess improvement in neurological symptoms through regular follow-up evaluations 2
• Consider gastrointestinal protection in patients at higher risk of bleeding 2
• Ensure comprehensive management of other vascular risk factors (hypertension, diabetes, dyslipidemia) 1, 6