What medications do people with Cerebrovascular Accident (CVA) take?

Medications for Cerebrovascular Accident (CVA) Management

Antiplatelet Therapy for Non-Cardioembolic Stroke

For patients with ischemic stroke or TIA of non-cardioembolic origin, antiplatelet therapy is the cornerstone of secondary prevention, with three equally recommended first-line options: aspirin 75-325 mg daily, clopidogrel 75 mg daily, or the combination of aspirin 25 mg plus extended-release dipyridamole 200 mg twice daily. 1, 2

First-Line Antiplatelet Options

• Aspirin monotherapy: 75-325 mg daily (most commonly 81 mg for maintenance) reduces the combined risk of non-fatal MI, non-fatal ischemic stroke, and vascular death by approximately 15 events per 1000 patients treated annually 1

• Clopidogrel monotherapy: 75 mg daily is equally effective to aspirin and may be preferred in patients with aspirin hypersensitivity or gastrointestinal intolerance 1, 2

• Aspirin plus extended-release dipyridamole: 25/200 mg twice daily is superior to aspirin alone for stroke prevention (Class I, Level B evidence), though it carries a slightly higher bleeding risk (4.1% vs 3.6% major hemorrhagic events) 1, 2

Critical Antiplatelet Therapy Caveats

• Dual antiplatelet therapy with aspirin plus clopidogrel is NOT recommended beyond 21-30 days after the initial stroke event, as it significantly increases hemorrhage risk without additional stroke prevention benefit 1, 2

• The PROFESS trial demonstrated no superiority between aspirin/dipyridamole versus clopidogrel monotherapy (9% vs 8.8% recurrent stroke rate), making either regimen acceptable 1

• Antiplatelet agents are strongly preferred over oral anticoagulation for non-cardioembolic stroke (Class I, Level A evidence) 1

Lipid-Lowering Therapy

All patients with ischemic stroke should receive high-intensity statin therapy with atorvastatin 80 mg daily, targeting an LDL-cholesterol level below 70 mg/dL (1.8 mmol/L). 2

• Statin therapy reduces cardiovascular events by 37% and stroke by 48% in patients with atherosclerotic disease, even when baseline lipid levels are normal 1

• If LDL goals are not achieved with statin monotherapy, add ezetimibe to reach target levels 2

• For diabetic patients with extracranial cerebrovascular disease, atorvastatin 80 mg daily is specifically recommended for stroke prevention 1

Antihypertensive Therapy

Target systolic blood pressure below 140 mmHg for all stroke patients, with particularly strict control for those with moderate to high-grade intracranial atherosclerotic stenosis. 2

• The specific antihypertensive agent class should be selected based on comorbidities (heart failure, diabetes, chronic kidney disease), though achieving the blood pressure target is more important than the specific agent used 2

• Aggressive blood pressure control is more effective than glucose control alone in reducing recurrent stroke rates in diabetic patients 1

Anticoagulation for Specific Stroke Etiologies

Cardioembolic Stroke (Atrial Fibrillation)

• Direct oral anticoagulants (DOACs) are preferred over warfarin for stroke prevention in atrial fibrillation 2

• If warfarin is used, target INR 2.5 (range 2.0-3.0) 3

• For patients with mechanical heart valves and prior stroke, warfarin targeting INR 2.5-3.5 plus aspirin 75-100 mg daily is recommended 2, 3

Extracranial Artery Dissection

• Either antiplatelet therapy or oral anticoagulation for at least 3 months is acceptable 2

Embolic Stroke of Undetermined Source (ESUS)

• Antiplatelet therapy is recommended rather than oral anticoagulation 2

Special Populations and Emerging Evidence

Cerebral Venous Thrombosis

• For acute CVT, low-molecular-weight heparin (LMWH) or unfractionated heparin should be used first-line, even in the presence of hemorrhagic transformation 4, 5

• DOACs (rivaroxaban or dabigatran) are emerging as safe alternatives to warfarin for CVT, with rivaroxaban showing better thrombus resolution and reduced recurrence compared to standard anticoagulants 6, 4, 5

• Warfarin may be used in the sub-acute phase for secondary prevention, but DOACs are increasingly preferred despite limited guideline endorsement 4, 5

COVID-19 and Vaccine-Related CVT

• Vaccine-induced immune thrombotic thrombocytopenia (VITT) requires non-heparin anticoagulants combined with immunotherapy and steroids, not standard heparin-based therapy 4, 5

• The incidence of vaccine-related CVT is extremely low (<5 per million doses), with benefits far outweighing risks 5

Glucose Management in Diabetic Stroke Patients

• Glucose-lowering medications are beneficial for diabetic patients with cerebrovascular disease, though intensive glucose control to HbA1c <7.0% has not been proven to specifically prevent stroke 1

• Screen all stroke survivors with fasting glucose assessment, repeating every 3 years 6

Common Pitfalls to Avoid

• Never use full-intensity parenteral anticoagulation (unfractionated heparin or LMWH) for acute ischemic stroke of atherosclerotic origin—this is Class III (no benefit) evidence 1

• Avoid combining aspirin with clopidogrel beyond the acute period (first 21-30 days), as hemorrhage risk increases by 1.3% absolute risk without additional benefit 2, 7

• Be aware that 25-30% of patients may exhibit aspirin or clopidogrel resistance due to genetic factors (CYP2C19 polymorphisms) or drug interactions, particularly with proton pump inhibitors 1, 6, 7

• For patients on clopidogrel, avoid concurrent use of PPIs that inhibit CYP2C19, as this reduces clopidogrel's antiplatelet effect 7