What are common medications for individuals with a history of cerebrovascular accident (CVA)?

Common Medications for Individuals with a History of Cerebrovascular Accident

For long-term secondary stroke prevention after a cerebrovascular accident, antiplatelet therapy is the cornerstone of treatment, with aspirin (81-325 mg daily), clopidogrel (75 mg daily), or aspirin plus extended-release dipyridamole (25/200 mg twice daily) as first-line options, combined with high-dose statin therapy and blood pressure management. 1

Antiplatelet Therapy (Primary Medication Class)

For Non-Cardioembolic Stroke

Single antiplatelet therapy is the standard long-term approach:

• Aspirin 81-325 mg daily is recommended for secondary stroke prevention 1
• Clopidogrel 75 mg daily is an alternative option with similar efficacy 1
• Aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily is another recommended combination 1

Important caveat: Dual antiplatelet therapy (aspirin plus clopidogrel) is NOT recommended beyond 21-30 days after the initial event, as it increases bleeding risk without additional benefit 1

For Patients with Atrial Fibrillation

Oral anticoagulation replaces antiplatelet therapy:

• Direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for patients with nonvalvular atrial fibrillation and prior stroke 1
• Patients suitable for anticoagulation should NOT receive antiplatelet therapy for secondary stroke prevention 1
• For valvular atrial fibrillation (mechanical valve or moderate/severe mitral stenosis), vitamin K antagonists are required 1

Lipid-Lowering Therapy

High-dose statin therapy is essential:

• Atorvastatin 80 mg daily is recommended for patients with ischemic stroke or TIA, particularly those with intracranial atherosclerotic stenosis 1
• Target LDL-cholesterol level should be <1.8 mmol/L (70 mg/dL) 1
• For patients with atherosclerotic disease of extracranial or intracranial arteries, ezetimibe can be added to reach LDL goals 1

Blood Pressure Management

Antihypertensive medications are critical:

• Target systolic blood pressure <140 mmHg is recommended for patients with moderate to high-grade intracranial atherosclerotic stenosis 1
• The specific antihypertensive agent class should be selected based on individual comorbidities, though the blood pressure target itself is the priority 1

Special Populations and Scenarios

Embolic Stroke of Undetermined Source (ESUS)

• Antiplatelet therapy is recommended rather than oral anticoagulants 1
• Patients with ESUS should NOT receive oral anticoagulants 1

Extracranial Artery Dissection

• Either antiplatelet therapy OR oral anticoagulants for at least 3 months are acceptable options 1

Carotid Web or Fibromuscular Dysplasia

• Antiplatelet therapy is recommended 1

Patients with Mechanical Heart Valves

• Warfarin targeting INR 2.5-3.5 plus aspirin 75-100 mg daily for mechanical mitral valves with prior stroke 1

Common Pitfalls to Avoid

Critical timing considerations:

• Do NOT use dual antiplatelet therapy (aspirin plus clopidogrel) as routine long-term therapy beyond 21-30 days post-stroke, as bleeding risk outweighs benefit 1
• Do NOT combine antiplatelet therapy with anticoagulation in patients with atrial fibrillation unless there is a specific indication like recent coronary stenting 1
• Do NOT use anticoagulation for embolic stroke of undetermined source, as trials have shown no benefit over antiplatelet therapy 1

Medication selection errors:

• Do NOT use aspirin alone when oral anticoagulation is indicated for atrial fibrillation—anticoagulation is superior 1
• Do NOT continue dual antiplatelet therapy indefinitely after carotid stenting; transition to single antiplatelet therapy after 1-3 months 1

Algorithm for Medication Selection

Step 1: Determine stroke mechanism

• Cardioembolic (atrial fibrillation) → Oral anticoagulation (DOAC preferred) 1
• Non-cardioembolic → Antiplatelet therapy 1
• ESUS → Antiplatelet therapy only 1

Step 2: Select antiplatelet regimen (for non-cardioembolic)

• Choose ONE of: aspirin 81-325 mg daily, clopidogrel 75 mg daily, or aspirin/dipyridamole combination 1

Step 3: Add statin therapy

• Atorvastatin 80 mg daily for all patients with ischemic stroke 1

Step 4: Optimize blood pressure

• Target systolic BP <140 mmHg with appropriate antihypertensive agents 1

Step 5: Monitor and adjust

• Lipid levels at 1-3 months, then every 3-12 months 1
• INR monitoring if on warfarin (target 2.0-3.0 for most indications) 1