Do patients with stroke-like symptoms need to be on Aspirin (Acetylsalicylic Acid) and Plavix (Clopidogrel)?

Dual Antiplatelet Therapy for Stroke-Like Symptoms

For patients with very high-risk TIA (ABCD2 score >4) or minor stroke (NIHSS 0-3) of noncardioembolic origin, dual antiplatelet therapy with aspirin and clopidogrel should be initiated within 24 hours and continued for 21-30 days, followed by monotherapy. 1

Immediate Management Based on Stroke Severity

High-Risk TIA or Minor Stroke (NIHSS 0-3)

• Loading doses required: Give clopidogrel 300-600 mg plus aspirin 160 mg immediately after brain imaging excludes hemorrhage 1
• Maintenance therapy: Continue aspirin 81 mg plus clopidogrel 75 mg daily for 21-30 days 1
• Timing is critical: Start dual therapy within 24 hours of symptom onset, ideally within 12 hours, and before ED discharge 1
• After 21-30 days: Switch to monotherapy (aspirin or clopidogrel alone) and continue indefinitely 1

The evidence supporting this approach is robust. The POINT trial demonstrated that dual antiplatelet therapy reduced ischemic stroke risk from 6.3% to 4.6% (HR 0.72, p=0.01), preventing 15 ischemic strokes per 1000 patients treated, though causing 5 additional major hemorrhages 1. The CHANCE trial showed similar benefits with 21-day treatment 1.

Moderate-to-Severe Stroke or Noncardioembolic Stroke

• Aspirin monotherapy is appropriate: Give aspirin 160 mg loading dose immediately after imaging excludes hemorrhage 1
• Continue aspirin 81-325 mg daily indefinitely 1, 2
• Do NOT use dual antiplatelet therapy in this population—the bleeding risk outweighs benefits 1

Key Contraindications and Timing Restrictions

When NOT to Use Dual Antiplatelet Therapy

• Active bleeding or intracranial hemorrhage: Absolute contraindication 3
• After thrombolysis (alteplase): Delay any antiplatelet therapy until 24-hour post-thrombolysis scan excludes hemorrhage 1
• Long-term dual therapy (>30 days): Increases bleeding and mortality without additional benefit 1
• Cardioembolic stroke: Use anticoagulation instead of antiplatelets 1

Special Surgical Considerations

• Urgent carotid endarterectomy planned: Consider aspirin monotherapy rather than dual therapy to reduce perioperative bleeding risk 1
• Coordinate with surgeon regarding timing and selection of antiplatelet agents 1

Risk Stratification for Dual Therapy Decision

Use dual antiplatelet therapy if patient meets BOTH criteria:

1. High-risk features: ABCD2 score >4 OR minor stroke with NIHSS 0-3 1
2. Noncardioembolic etiology: No atrial fibrillation, mechanical valve, or cardiac thrombus 1

Use aspirin monotherapy if:

• Moderate-to-severe stroke (NIHSS >3) 1
• Cardioembolic source identified 1
• Presentation >24 hours after symptom onset 1
• High bleeding risk (active ulcer, recent major bleeding) 3

Practical Implementation Details

Dysphagia Management

• Enteral tube: Aspirin 80 mg plus clopidogrel 75 mg daily 1
• Rectal route: Aspirin 325 mg suppository daily 1

GI Protection

• Consider proton pump inhibitor in patients at higher GI bleeding risk on dual therapy 1
• Avoid omeprazole and esomeprazole as they significantly reduce clopidogrel's antiplatelet activity 3
• Acceptable alternatives: Dexlansoprazole, lansoprazole, or pantoprazole have less effect on clopidogrel 3

Genetic Considerations

• CYP2C19 poor metabolizers: Clopidogrel forms less active metabolite and has reduced efficacy 3
• Consider alternative P2Y12 inhibitor if genetic testing identifies poor metabolizer status 3

Common Pitfalls to Avoid

Do not continue dual therapy beyond 30 days unless there is a separate indication (e.g., coronary stent)—this increases major bleeding from 0.4% to 0.9% without additional stroke prevention benefit 1

Do not add clopidogrel to aspirin in established stroke patients beyond the acute 21-30 day window—long-term combination therapy increases bleeding and mortality 1

Do not use dual antiplatelet therapy as substitute for anticoagulation in patients with atrial fibrillation—the combination carries similar bleeding risk to warfarin without the stroke prevention benefit 1

Do not delay dual therapy initiation—benefit is greatest when started within 12 hours and diminishes significantly after 24 hours 1