What else can I give to a patient already on aspirin (acetylsalicylic acid) for stroke prevention?

Additional Antiplatelet Options for Patients Already on Aspirin for Stroke Prevention

For patients already taking aspirin who experience a noncardioembolic ischemic stroke or TIA, switching to clopidogrel 75 mg daily is a reasonable alternative, though there is limited evidence that changing antiplatelet agents provides additional benefit. 1

Primary Recommendation: Switch to Alternative Single Antiplatelet Agent

• The effectiveness of increasing aspirin dose or switching to another antiplatelet medication is not well established for patients who have an ischemic event while on aspirin 1, 2
• Clopidogrel 75 mg daily can be considered as an alternative to aspirin, particularly if rapid action is needed with a 300 mg loading dose followed by 75 mg maintenance 1
• Aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily is another guideline-recommended option for secondary prevention 1, 2

Short-Term Dual Antiplatelet Therapy (DAPT) for High-Risk Situations

If the patient has had a recent minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4), dual antiplatelet therapy should be initiated:

Aspirin Plus Clopidogrel Regimen

• Start within 12-24 hours of symptom onset (no later than 7 days) 1, 2
• Continue for 21-90 days, then return to single antiplatelet therapy 1, 2
• This approach significantly reduces recurrent stroke risk in the early high-risk period 1

Aspirin Plus Ticagrelor Regimen (Alternative)

• For patients with recent minor-moderate stroke (NIHSS ≤5) or high-risk TIA (ABCD2 ≥6) 1
• Ticagrelor 90 mg twice daily plus aspirin for 30 days may reduce 30-day recurrent stroke but increases bleeding risk including intracranial hemorrhage 1
• Requires loading doses of both medications 1

Special Considerations Based on Stroke Etiology

Intracranial Large Artery Atherosclerosis (50-99% stenosis)

• Aspirin 325 mg daily is preferred over warfarin 1, 2
• For severe stenosis (70-99%): Add clopidogrel 75 mg to aspirin for up to 90 days 1
• Cilostazol 200 mg/day added to aspirin or clopidogrel might be considered, though evidence is primarily from Asian populations 1
• Ticagrelor 90 mg twice daily plus aspirin for 30 days may be considered if ≥30% ipsilateral intracranial stenosis (9.9% vs 15.2% recurrent stroke rate, HR 0.66) 1

Cardioembolic Stroke

• Oral anticoagulation is preferred over antiplatelet therapy for cardioembolic sources 2
• Evaluate for atrial fibrillation, left ventricular thrombus, or other cardiac sources requiring anticoagulation 1

Critical Contraindications to DAPT

Do not use dual antiplatelet therapy if:

• Severe uncontrolled hypertension 2
• Known allergies to aspirin or clopidogrel 2
• Hemophilia or other bleeding disorders 2
• Continuous DAPT beyond 90 days is associated with excess hemorrhage risk 1

Essential Concurrent Management

Regardless of antiplatelet choice, ensure:

• Blood pressure control to <140 mm Hg systolic 1
• High-intensity statin therapy 1
• At least moderate physical activity 1

Common Pitfall to Avoid

Do not simply increase the aspirin dose for patients who have an event while on aspirin—there is no evidence this provides additional benefit 1, 2. Instead, switch to an alternative antiplatelet agent or add a second agent for the appropriate short-term duration based on stroke characteristics.